Dual diagnosis toolkitMental health and substance misuse

A practical guide for professionals and practitioners

Contents

• Who should use this toolkit? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 1

• What does this toolkit contain? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 1

• Accompanying materials • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 1

• What is dual diagnosis? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 2

• How common is dual diagnosis? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 2

• The relationship between substance misuse and mental health • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 3

Page

Section One – Introduction

• Frameworks for practice • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 5

Section Two – The policy frame work for dual diagnosis

Section Three – Substance Use

Foreword

About the authors

Acknowledgements

• Types of mental illness: • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 15

• Anxiety Disorders • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 15

• Depression • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 16

• Schizophrenia • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 17

• Bipolar Disorder/Manic Depression • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 18

• Schizoaffective Disorder • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 19

• Personality Disorders • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 19

Section Four – Mental Health

• What is a drug? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 9

• What is the difference between drug use and misuse? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 9

• Why do people misuse substances? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 10

• Patterns of substance use • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 11

• Type of use • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 12

• How common is substance misuse? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 13

• Service delivery • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 57

• Social care • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 58

• Ideas for better integration between services • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 60

• Identifying and meeting training need • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 63

• Good practice needs • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 64

Section Six – Structures

• The assessment process • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 23

• Assessing and managing risk • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 26

• Understanding and using the Care Programme Approach • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 30

• Care Planning • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 32

• Person-centred Planning • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 32

• Treatment • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 33

Types of treatment offered by substance misuse services • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 34

Accessing treatment for substance misuse • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 36

Interventions via the criminal justice system • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 37

Interventions via The Mental Health Act • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 38

Types of treatment offered by mental health services • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 39

Types of medication • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 39

Types of psychosocial therapy • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 40

Complementary therapies • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 43

Stages in treatment of dual diagnosis • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 43

Involving service users, families and carers in treatment • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 49

• Meeting diverse needs: • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 50

Section Five – In Practice

References and Resources • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 69

Appendix 1 – What substances do people use and what are their effects? • • • • • • • • • • • • • • • 72

Appendix 2 – Dual Diagnosis in the Policy Context • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 81

Further Reading • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 86

Useful Addresses • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 89

Index • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 97

ForewordDual diagnosis is not a new issue. The relationship between mental health and problematic substancemisuse has a long and complex history. However, it is only comparatively recently that practitioners andpolicy makers have acknowledged the huge scale of the problem and begun to tackle the complex task ofdelivering appropriate care. We have written this toolkit to support the practitioners who deliver that care.

The core challenge is to co-ordinate disparate services to provide holistic care. There is usually little pointin providing treatment unless we also recognise that people need homes, meaningful activity, adequateincome, social networks and access to jobs and/or training. Whilst everybody accepts the principle ofholistic care, in practice there are real barriers between services. That is why this toolkit is a deliberateattempt to build bridges and promote mutual learning.

Our purpose is to help a practitioner working in one field to develop a better understanding of otherrelevant service areas – the key issues, service frameworks, types of treatment, how to access them, and pointers to good practice.

As leading service providers, Rethink and Turning Point hope that our collaboration embodies the spirit of co-operation that we advocate. Only by working together can we provide care that is realistic andpragmatic and that genuinely enables people to move forward.

We hope you will find this toolkit both inspirational and useful.

“Co-ordinated personalised treatmentand recognition of a person’s need

for a home, friends, money andmeaningful activity are crucial. Taken

together, these can be a passport to long-term recovery.”

“Practitioners can be experts in their own field but unsure

of how other relevant services work.We hope this toolkit will build

bridges to promote understanding, co-operation and better outcomes

for people affected.”

Lord Victor Adebowale Chief Executive, Turning Point

Cliff Prior Chief Executive, Rethink

About the authorsThis toolkit is a partnership between Rethink and Turning Point.

The authors are:Caroline Hawkings, Mental Health Policy and Campaigns Officer at Turning Point and Helen Gilburt,Information Officer, from the National Advice Service at Rethink.

Additional materials and case studies were researched and written by Liz Aram of The Forster Company.

Turning PointTurning Point is the UK’s leading social care organisation providing services for people with complexneeds across a range of health and disability issues. It is the largest provider of substance misusetreatment services and a major provider of mental health and learning disability services. Last year,Turning Point had contact with almost 100,000 people through services in 200 locations in England and Wales. Turning Point provides services for people with concurrent mental health and substancemisuse problems.

Registered Office: New Loom House101 Back Church LaneLondon, E1 1LUTel: 020 7702 2300Website: www.turning-point.co.ukE-mail: info@turning-point.co.uk

Registered Charity Number: 234887Registered Social Landlord and Company Limited by Guarantee in England and Wales (no.793558)

RethinkRethink has more than 30 years experience of helping people with severe mental illness and their families recover a meaningful life. As well as running over 400 mental health services, Rethink has a network of more than 120 support groups across the country.

Head Office:30 Tabernacle StreetLondon EC2A 4DDTel: 0845 456 0455Fax: 020 7330 9102Website: www.rethink.org E-mail: info@rethink.org

Registered Charity Number: 271028Company Registered in England (no.1227970)

AcknowledgmentsRethink and Turning Point gratefully acknowledge the support and funding of the Home Office in theproduction of this toolkit and the range of other materials for this initiative.

We would also like to thank the following people for their help and advice:

Gabrielle Ayerst, Senior Advice Worker, Anton Buxton, Information Officer, and Mary Teasdale, Head of theNational Advice Service, at Rethink for their advice on content and style.

Eddie Greenwood, Director of Clinical Services at Rethink.

The Turning Point Steering Group, particularly: Jill Bell, Eloise Cooper, Richard Kramer, Danny Mann, Chris Rowland, Terry Thomas and Darren Woodward. Also thanks to Vania Desborough for her assistancewith research.

All Turning Point and Rethink staff and service users who contributed to and commented on the drafts.

Mr Euan Hails, Thorn Programme Leader, Section of Psychiatric Nursing and Professor Kevin Gournay of the Institute of Psychiatry in London, for some of their training materials. These have been incorporatedinto the Dual Diagnosis Toolkit in the section on stages in treatment.

Colin Brazier of the CASA Multiple Needs Service for his permission to incorporate material from CASA’sarticle ‘Perspectives on Multiple Needs – working with individuals who experience mental health &substance misuse problems’ (see ‘Meeting Diverse Needs’ page 50).

The Kaleidoscope Project in Kingston upon Thames for its permission to draw on its research onantecedent factors to addictive behaviour which was published in ‘No Quick Fix’ by Rev Eric BlakebroughMBE, and for its support in providing feedback, ideas and case studies.

Carmel Clancy, Senior Lecturer in Mental Health and Addictions, School of Health and Social Sciences,Middlesex University and Project Manager for the Royal College of Psychiatrists’ Dual Diagnosis project.

The many practitioners and service users who provided advice, feedback and case studies. In particular,Elizabeth Brewin of the Institute of Psychiatry, King’s College London and Cheryl Kipping from the SouthLondon and Maudesley NHS Trust.

Mind in Croydon for permission to draw upon its video, ‘Pillar to Post’, a film about dual diagnosis. To obtaina copy of the video please contact: Mind in Croydon, 26 Pampisford Road, Purley, Surrey CR8 2NETel: 020 8668 2210 E-mail: admin@mindincroydon.org.ukWebsite: www.mindincroydon.org.uk

We are grateful to several organisations for permission to adapt or reproduce information as follows:

Drugscope, for material from their website www.drugscope.org.uk and ‘Guide to Drugs’ used in Appendix 1.

The Royal College of Psychiatrists, for material from ‘Co-existing problems of Mental Disorder andSubstance Misuse (dual diagnosis) - an Information Manual’.

Section oneIntroductionWho should use this toolkit?This toolkit is written for frontline staff working with adult clients who have a combination of substance misuse and mental health problems. They may be working in a variety of settings in both the statutory and voluntary sectors. The impetus for the toolkit was the recognition that people working withinsubstance misuse would benefit from a basic understanding of mental health services and vice versa.

In addition, workers in a broad range of community-based services also provide relevant care including people insocial services, housing, probation, prison services, primary care, hospital wards and Accident and Emergency.

Whilst the toolkit is not specifically aimed at dual diagnosis specialists, it may be useful to them inproviding references and signposts to further information. We also hope that specialists will provide a vital dissemination link to frontline workers.

Similarly, although the toolkit is not aimed at service users and carers, they may also find it useful. (Rethink has also produced a shorter leaflet that is aimed at carers.)

What does the toolkit contain?The toolkit is both a practical guide and a reference source. It provides a basic introduction to key issues,service models and good practice in both substance misuse and mental health. The material is arranged so thatbusy practitioners can quickly identify the information they need without having to read the whole document.

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What is dual diagnosis?

“Dual diagnosis is a label they give you, but even at my most buoyant I think I’ve got more than two problems.”

Service user

“In short, an individual’s needs are often multiple rather than dual and include social as well as medical needs.”

Lehman et al 1989 quoted by The Centre for Research on drugs and health behaviour

There is no common understanding about what is meant by “dual diagnosis”. For the purposes of this toolkit, we have defined it as: ‘the co-existence of mental health and substance misuse problems’.

For services, diagnostic labels have value in defining a client group and enabling the commissioning anddelivery of care. However, practitioners should be aware that both service users and staff often see thelabel “dual diagnosis” as problematic.

“Dual” diagnosis can suggest that there are only two problems. In fact many people have multiple needs.These might include one or more medical problems and a range of social issues such as housing, income,employment and social isolation. In practice, people are usually only given a formal diagnosis of dualdiagnosis if they have severe mental health problems (generally psychotic disorders) and severe substancemisuse problems that meet the criteria for specialist services. The issue then arises of how to accessappropriate care for people whose problems, whilst distressing, are not considered “serious” enough tomeet the threshold for specialist care. For example someone who has serious substance misuse problemsbut “moderate” mental health problems (such as anxiety or depression) or vice versa.

The term “dual diagnosis” does not specify the disorders and so could potentially apply to a person withany two conditions eg a learning disability and a mental health problem.

A label of dual diagnosis can lead to stigma and barriers in accessing services. Paradoxically, it can alsobe a passport to services, especially when specialist care is in short supply. It is important to note that thelabel “dual diagnosis” does not indicate a specifically new condition but rather identifies that the personhas concurrent issues.

How common is dual diagnosis?In the UK it is estimated that a third of patients in mental health services have a substance misuseproblem. At the same time, around half of patients in drug and alcohol services have a mental healthproblem (most commonly depression or personality disorder1). In a major study2 of people involved in substance misuse treatment, one in five people reported recent psychiatric treatment. Prevalenceamongst the prison population is high. A study3 by the Office of National Statistics indicated that:

10% of male remand prisoners had moderate dependency40% had severe dependency79% of male remand prisoners who were drug dependent had two additional mental disorders

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What is the relationship between substance misuseand mental health?The relationship is complex, controversial and varies from individual to individual. ‘The Dual Diagnosis Good Practice Guide’ from the Department of Health describes four possible relationships:

• A primary psychiatric illness precipitates or leads to substance misuse• Use of substances makes the mental health problem worse or alters its course• Intoxication and/or substance dependence leads to psychological symptoms• Substance misuse and/or withdrawal leads to psychiatric symptoms or illnesses

There is a range of factors that may make some people more vulnerable to either or both problems. These include genetic make up, environment and behaviour. The triggers are also diverse and may include a range of adverse life events such as homelessness, relationship breakdown or bereavement.

There remains debate about the extent to which substance use can cause mental illness. Drug inducedpsychosis is one area of study as are the effects of cannabis. There is more agreement that substancemisuse may trigger or exacerbate mental illness. However, in practice it may be difficult to identifywhether use caused the problem or is merely associated with it. Substance misuse can also mask a mental health problem which is then revealed when use is decreased. For example, a person with anxiety or depression may use stimulants as a means of coping with their situation.

It is important to recognise that people’s mental health and substance misuse problems may vary overtime. For example:

• People may vary the type and amount of substances they use – eg they may stay clear of illegal drugsbut use alcohol or cannabis occasionally

• They may react differently to the same substance depending on the supply, their environment or their general health• Their mental health problems may fluctuate. For example they may have episodes of ill health followed

by long periods of stability• Fluctuating vulnerability – for example a person may be vulnerable to using alcohol during periods of mania

Case study

In her late twenties, Sally began experiencing deep periods of depression and unusual shifts in mood.She was diagnosed as having bipolar disorder in 1994, aged 32 and was prescribed lithium. Duringinitial assessment, she admitted to often not taking her medication when she felt well and this, andher escalating cocaine use, resulted in multiple compulsory hospital admissions under Section 3 ofThe Mental Health Act. Sally reported low self-esteem due to difficult family dynamics and said thatcocaine made her feel more confident, but also made her take risks, which frightened her.

Counselling and support began whilst Sally was in hospital. This built on Sally’s wish to control her illness and lead a “more productive” life. Sally began to realise that, to help reach her goals she needed to take her medication. She acknowledged that it helped “keep me well” and that, if she experienced side effects, she could talk to her care team. She also recognized that her cocaine use exacerbated her mental illness and put her at risk of sexual and financial exploitation.

Sally was able to remain drug free while in hospital, but realized that on discharge, this would be more difficult to maintain. Cocaine had left “a hole” in her life and it was important to replace it with meaningful activity. She therefore attended relapse prevention sessions and life skills groups run by a local voluntary agency and also looked forward to the complementary therapies on offer. Sally remains drug free and has had no hospital admission for over a year. She is currently studyingbeauty therapy in the hope of working in the future.

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Section twoThe policy framework for dualdiagnosisIn this section we alert practitioners to two frameworks for practice produced by the Department of Healthand the Royal College of Psychiatrists. We also provide a brief summary of key areas of policy that arerelevant to dual diagnosis. Fuller descriptions of these can be found in Appendix 2 on page 81.

Practitioners should be aware that policy tends to focus on people with more severe problems who have been given a formal label of dual diagnosis.

Frameworks for practiceWe particularly refer practitioners to two sets of guidelines:

Dual Diagnosis Good Practice Guide

Published by the Department of Health, this summarises current policy and good practicewith emphasis on the provision of mental health services for people with severe mentalhealth problems and problematic substance misuse.

The guide clarifies lead responsibilities and sets out ways in which substance misuse andmental health should work with and support each other. Its key provisions include:

• The primary responsibility for the treatment of individuals with severe mental illness and problematicsubstance misuse should lie within mental health services. This approach is referred to as ‘mainstreaming’,and aims to lessen the likelihood of people being shunted between services or losing contact completely

• Substance misuse agencies (both alcohol and drugs) should provide specialist support, consultancy and training to mental health teams

• Where clients have less severe mental health problems, mental health services should provide similarsupport to substance misuse agencies

• Clear pathways of joint working and treatment should be developed in dual diagnosis strategic planning

Local Implementation Teams (from mental health) and Drug Action Teams (from substance misuse) areresponsible for the implementation of the Guide’s requirements.

Co-existing problems of Mental Disorder and Substance Misuse(dual diagnosis) - an Information Manual

This is a more detailed resource for practitioners published by the Royal College ofPsychiatrists in 2002. It contains similar sections to those covered in this toolkit butprovides greater depth of discussion and good practice detail. The manual can bedownloaded free from: www.rcpsych.ack.uk/cru/complete/ddip.htm

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Other policy and service frameworks

The Mental Health National Service Framework (NSFMH)

Published in 1999, the NSFMH sets out how services will be planned, delivered and monitored. Several areas are relevant to dual diagnosis including mental health promotion, primary care andspecialist services.

Two approaches to care are also particularly relevant:

The Care Programme Approach (CPA) is a framework for inter-agency working. It seeks to ensure that clients have a proper assessment and that services are co-ordinated in line with client need.

Assertive outreach and crisis resolution services are proactive approaches to engaging with clients and managing problems.

Models of Care (MoC)

This is effectively the comparable framework for substance misuse services. Although it does not have the formal status of a National Service Framework, it has similar aims in terms of specifying howservices will be planned, delivered and monitored.

MoC emphasises care co-ordination and meeting multiple client needs through an integrated pathway of care. To this end, it groups services into four tiers and outlines the relationships between them. Thetiers are set out in this toolkit in the ‘In Practice’ section on page 36.

The Mental Health Act 1983

This Act sets out the circumstances in which an individual can be detained (sectioned) in hospital for assessment and/or treatment for their mental disorder without their consent. The ‘References andResources’ section explains the sections that are most commonly used (see page 83). It should be noted that this Act is currently under review.

The Mental Health Act contains several different sections. More information is available fromwww.imhap.com

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The National Alcohol Harm Reduction Strategy for England

Published in March 2004, this document sets out the Government’s strategy for tackling the harms andcosts of alcohol misuse in England. The strategy recognises the need for co-ordination of services andcommits to working within the Models of Care framework on integrated care pathways.

Updated Drug Strategy

Published by the Drug Strategy Directorate at the Home Office in 2002, the strategy aims to reduce theharm that drugs cause to society, including communities, individuals and their families.

The Social Exclusion Report – Mental Health and Social Exclusion

Published in June 2004, this document examines how to attack the cycle of deprivation linked to mentalhealth problems (including considering the role of substance misuse). Both the National Institute forMental Health (England) (NIMHE) and the National Treatment Agency for Substance Misuse (NTA) haveagreed to take forward work in this area recommended by the report.

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Section threeSubstance useThis section is designed to give practitioners an introduction to some of the issues and conceptsinvolved in substance misuse. It includes:

• What is a drug?• The nature of use and misuse • Why do people misuse? • Patterns of misuse• How common is substance misuse?

In the ‘In Practice’ section on page 33-35 we include details of a range of treatments available fromsubstance misuse services.

In Appendix 1 on page 72 we include a description of the substances that are most commonly misused.

What is a drug?Drugs have been described as: ‘any substance that, by its chemical nature, alters the structure orfunctioning of a living being’.

This is obviously a very broad definition that takes in a wide range of everyday socially acceptedsubstances (coffee, tea) right through to illegal class A drugs. Nevertheless, an inclusive description can have some value in helping practitioners understand patterns of use and difficulties of changing or reducing use:

“We try to get staff to think about their own addictions – how difficult it is to lose weight, to stop drinking so much tea or coffee, give up cigarettes, cut down

on social drinking. How ready are they to give up experiences that are pleasurable? It helps them think about the complexity and difficulty of change.”

Dual diagnosis trainer

However, of more immediate concern to the practitioner is to understand different patterns of use andwhen substance use becomes problematic.

What is the difference between drug use and misuse?Many of us use legal drugs like caffeine, nicotine, or alcohol without much thought. Their use is sociallyacceptable and, in some circumstances, encouraged. We may even consume unwise levels or have atemporary dependency without having a long-term dependency problem. It is important to note that somepeople may also take illegal drugs occasionally without being dependent on them – eg a recreationalcocaine user.

The line between use and misuse is a fine one and will vary from individual to individual. However, a usefulworking definition of use and misuse has been developed by the drugs agency, Drugscope:

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Drug use: this refers to the taking of a drug, either by swallowing, smoking, injecting or any other way of getting it into the bloodstream. Drug use is used to refer to drug taking that, although it has some risk, is not necessarily wrong or dangerous. The term does not imply that drug taking is wrong and istherefore preferred by many not wishing to value-judge the taking of drugs.

Drug misuse: implies use outside medical use and which is harmful or done in a wrong way. It refers touse that is dependent or part of a problematic or harmful behaviour. This is preferable to the older termdrug ‘abuse’ which can imply a moral judgement.

Why do people misuse substances?“I’d just got out of prison. I got straight back on the ‘gear’ again,

‘cos my missus, my kids, my home - everything had gone.”Service user

The reasons why people use will be as varied as the individuals themselves. Some may enjoy the experience,wish to improve their sex life or hope to lose weight. Others who are socially excluded may find a sense ofcommunity with other drug users. For some, drug taking may be an escape from too much pressure. Forothers, it may be that boredom; peer pressure or a lack of opportunity is a trigger. Either way, it can be alltoo easy to create a vicious circle whereby using to escape problems only creates more problems andhence a greater need to escape.

Some people use to counter the withdrawal effects of other drugs. For example, benzodiazepines afterstimulants. Or they may combine drugs to enhance the effect – for example cocaine and ecstasy. Alternatively,people may take illegal drugs to counter the unpleasant side effects of prescribed medication - for examplemuscle spasms or movement disorders arising from mental health medication.

“In the environment where I am living, there are so many negative vibes, so many things to get you into trouble, so many things to

keep you down and keep you like on a depressive vibe. You have to smoke something to keep you up.”

Service user

“We say to people – you mustn’t take your drugs because they’re bad for you, they do bad things, they’re from bad people. Here are our drugs – they’re OK. But we don’t really subjectively understand what the experience of taking psychiatric drugs is.

Some have terrible side effects.”Drug worker

“Often the symptoms that the medication is addressing are not those that actually cause the client most distress. For example people

can be more concerned about anxiety and mood than about hearing voices. So then they can turn to street drugs to help them deal with social

situations or to take away the symptoms of medication.”Dual diagnosis nurse

The role of adverse life circumstances is also much discussed in relation to both mental health andsubstance misuse. Not only can deprivation in itself be a trigger but also there is generally greateravailability of drugs in deprived areas. The relationships between these factors is complex and beyond the scope of this toolkit to explore in detail.

Workers should however be mindful that, paradoxically, contact with health and social services could also make people more vulnerable. For example, clients discharged from hospital in receipt of benefits may be soft targets for drug dealers. There is also a worrying increase in the availability of illicit drugs in psychiatric wards.

Patterns of substance use

When considering patterns, the key factor is the amount taken and the effect on the person rather than issues around legality.

The legal status of a drug does not necessarily indicate how harmful it can be. The Governmentestimates that there are 3.8 million dependent drinkers in England and Wales. This is six times as many as those who are dependent on Class A drugs.

It is also worth noting that ‘harm’ can apply not only to the direct damage to the person but also to the behaviour associated with using. For example, there are known links between both alcohol and drugs and crime.

Factors affecting use

A number of factors may influence people’s use:

Environment/culture: Poor social support, lack of employment or meaningful activity or adverse workenvironment, peer pressure, family situation.

Mood: can fluctuate from optimism to low self-worth and despondency.

Plasticity: this means variability in the effects of a drug. For example, heroin has low plasticity so thateffects will be broadly similar for everyone. In contrast, LSD has high plasticity because its effects arevery variable.

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Types of useIt will be helpful for practitioners to know some of the terms used by substance misuse services todescribe different patterns of drug use: These are not rigid definitions and use can be problematic at any stage.

Experimental use can be seen as a normal developmental pattern. For example, it could apply to a school pupil inhaling solvents for the first time with friends. Other examples could include an ecstasy user who tried the drug once about 6 months ago and wants to try it again, or a person who has grown up with no drugs or alcohol but gets drunk with friends to see how it feels.

The numbers of those experimenting are steadily increasing and the age of first time use is decreasing.However, experimental use tends to be random and is usually sociable. It is important to note that it doesnot necessarily lead to dependency - the “slippery slope” theory is not borne out by research.

Recreational use differs from experimentation, in that it is both regular and controlled and can also bestopped at any time. It applies to both legal and illegal substances and is usually a sociable experience.Examples could include a person who smokes cocaine every other month with their partner or someonewho drinks alcohol at the weekend who doesn’t consider this to be problematic.

Polydrug use. This is use of more than one drug by the same individual, either in a drug “cocktail” or one after the other.

Dependent use describes a compulsion to continue taking a drug in order to feel good or avoid feelingbad. This term is preferable to “addiction” which has negative connotations.

Dependence is often described as either physical or psychological. Psychological dependence is central to the definition of drug dependence. Physical dependence is a common and often important, but not anecessary, element of drug dependence.

Psychological dependence usually includes a strong desire to take a drug even in the knowledge it isharmful, or in spite of negative consequences. In severe cases intense craving and prominent drug-seekingbehaviours are present.

Physical dependency is characterised by the need to take a substance to avoid physical discomfort orwithdrawal symptoms. This results from repeated, heavy use of drugs like heroin, tranquillisers and alcohol.This can change the body chemistry so that, without a repeat dose, a person suffers physical withdrawalsymptoms – such as “the shakes” and flu-like effects. For some drugs physical withdrawals can play amuch greater part in continuing to reinforce the dependence. For example, heroin has a much moreprominent physical dependence syndrome than drugs such as cannabis, or even cocaine.

Usually both the psychological and physical dependence on drugs are due to direct biological effects of the drug on the brain and nervous system. Common effects of most drugs that cause psychologicaldependence are direct or indirect changes in the brain reward and pleasure pathways. Physical withdrawalstend to be due to more specific nervous system changes related to the particular drug involved.

It is important to recognise that a range of individual biological, psychological and social factors canstrongly influence development of drug dependence. The importance of these factors varies from personto person, and for some may be of greater importance than the simple biological drug effects inmaintaining dependence of in contributing to relapse.

Other kinds of “behavioural addictions” are referred to such as work, gambling or sex addictions. Themechanisms involved are also complex and not fully understood. However, a range of individual biological,psychological and social factors are also involved including evidence of effects in brain reward pathways too.

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Binge – describes a pattern which involves episodic use of a substance in large amounts over acondensed period of time (which may be a period of hours, days or weeks), followed by little or no use.Often the period between binges becomes shorter and substance use becomes heavier and moreproblematic. Possible examples of binge using might include: a drinker who once a month consumes largeamounts of alcohol all weekend and who may have physical complaints, such as liver damage or alcoholpoisoning. Or, a crack cocaine user who spends large amounts of money, perhaps on the day the benefitscheque comes through, and then doesn’t use for some time.

Harmful use. This term should follow the ICD10 definition that ‘there must be clear evidence thatsubstance use was responsible for or substantially contributed to physical or psychological harm.’ It is interchangeable with problematic use. Examples include a drinker who consumes large quantities of alcohol every day. She develops a toleranceto alcohol and then needs larger quantities to feel intoxicated. She has regular binges of very heavy usethat affect her job and relationships. She knows that her drinking is a problem but is ambivalent aboutgetting help.

Chaotic use: This is often polydrug use, combined with other significant health issues eg HIV and liver damage, and mental health problems. It can be described as excessive use of substances over aprolonged period of time, with the user finding it very difficult to live without the substance or experiencingproblems stopping or regulating use. Such individuals may not appear to care or be aware of the dangersof their use

Note, when working towards change, it is important that these definitions are identified and accepted by the user.

How common is substance misuse?Estimates vary widely. The ‘Updated Drugs Strategy’ refers to 250,000 Class A drug users with the mostsevere problems. However, other research conducted by York University indicated a range of 280,000-500,000 people in the UK. According to the ‘Alcohol Harm Reduction Strategy for England’, 1.8 millionadults currently drink at very heavy levels. It is important to realise that the number of people in treatmentdoes not reflect the much larger number of people who are dependent.

Key findings from the British Crime Survey 2001/2

• Of all 16-59 year olds, 12% had taken an illicit drug and 3% had used a Class A drug in the last year.This equates to around four million users of any illicit drug and around one million Class A drug usersin the last year

• Cannabis is the most frequently used drug, with around 3 million of 16-59 year olds having used it in the last year

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Section fourMental health This section includes:

• A brief introduction to mental health problems highlighting some issues around diagnosis

• Descriptions of the main types of mental health problems giving prevalence figures and examples of symptoms

The treatments that are normally offered by mental health services are described in the ‘In Practice’section on page 39-42.

Most of us experience variations in our mental health from time to time. However for some people thesevariations are prolonged and can result in considerable disturbance to everyday life. This is the point atwhich a diagnosis of mental illness may be given.

It can be helpful to think of mental health in terms of a continuum. At one extreme would be positivewellbeing. This would include both medical and social factors and is a state of active good health ratherthan simply the absence of illness.

At the other end would be “serious and enduring” mental health problems. However, it is important torecognise that everyone is on this continuum and that most people fluctuate between different positions.Even people with “serious” conditions can have long periods of being well. This fluctuation is one of thereasons why many people feel uncomfortable about psychiatric labels and diagnoses. Such labels may not be a good predictor of somebody’s health at a given time and may lead to stigma and preconceptions.

Where a diagnosis is given this is because a doctor or psychiatrist recognises a number of symptoms and attributes them to a particular illness. However, practitioners should be aware that diagnosis is not an exact science. In practice, some symptoms can point towards two or more illnesses and misdiagnosiscan also occur. In other instances, conditions remain undiagnosed.

Types of mental illness

Anxiety disorders

According to the Mental Health Foundation, anxiety disorders are the most common form of psychiatricillness affecting around one in ten of the population.

Anxiety, worry and fear are feelings that everyone experiences from time to time. However, some people experience them with a severity that is out of proportion to the real threats around them. This can have a profound impact on their ability to function normally.

Diagnosis can be more complex in the event of dual diagnosis. On the one hand, anxiety disorders can be brought on by drink and drug use. On the other hand, people who have an anxiety disorder may use drink or drugs to deal with the symptoms.

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The general symptoms of anxiety disorders are:

• Feeling worried a lot of the time• Feeling tired• Difficulties concentrating• Being irritable• Problems sleeping• Heart palpitations• Heavy and rapid breathing• Dizziness• Feelings of dread or impending doom

Anxiety disorders include:

• Generalised anxiety disorder• Obsessive compulsive disorder• Panic disorder• Post traumatic stress disorder• Social anxiety disorder• Specific phobias• Separation anxiety disorder

One particular form of anxiety disorder is Post Traumatic Stress Disorder (PTSD). This is a pattern of behaviour that can occur after a traumatic experience or witnessing life threatening events such as serious accidents, violent personal assaults, sexual abuse or terrorist incidents. People with PTSD often re-live the experience through nightmares and flashbacks, have problems sleeping and feeldetached from reality. PTSD is complicated by the fact that it often occurs together with other mental health problems like depression, anxiety, memory problems and substance misuse.

Depression

The severity and length of depression can vary widely from a short-term reaction to an adverse event to a prolonged episode that interferes with the ability to function, feel pleasure or maintain interest.

It is estimated that one in five people will experience depression at some point in their lives and aboutone in 20 people have clinical depression.

Symptoms of depression include:

• Feelings of helplessness and hopelessness• Feeling useless, inadequate, bad• Self hatred, constant questioning thoughts and actions, an overwhelming need for reassurance• Being vulnerable and over sensitive• A loss of energy and motivation• Agitation and restlessness• Physical aches and pains

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In severe depression these feelings may also include:

• Suicidal ideas• Failure to eat or drink• Delusions and/or hallucinations

Sometimes depression may be masked – for example, by alcohol or drugs.

Schizophrenia

One in 100 people will experience schizophrenia during their lifetime.

Although for some people the illness may be chronic and enduring, many do recover and live ordinarylives. People are most likely to experience schizophrenia between their late teens and early twenties.

The causes of schizophrenia are still unclear though there are a number of theories. In relation to dualdiagnosis, practitioners should be aware that drug use has not been conclusively shown to causeschizophrenia (or other severe and enduring mental health problems). However, long-term use of certaindrugs could increase the chance of some people developing mental health problems.

There are two groups of symptoms. These are known as “positive” and “negative”. Positive symptomsmean that people have more experiences than normal whilst negative symptoms involve some loss ofnormal experience.

Positive symptoms

Hallucinations and illusionsHallucinations are perceptions that occur without connection to an appropriate source.

The most common hallucination is hearing voices. However, they can occur in any sensory form: auditory (sound), visual (sight), tactile (touch), gustatory (taste) and olfactory (smell).

Voices are usually thoughts in the mind. They can describe activities taking place, carry on aconversation, warn of dangers, or even issue orders. They can seem so loud that the person believes that they are audible to others around them.

To a person with schizophrenia, the voices appear to come from an external source. However, usingmodern imaging techniques, it is possible to see changes in the speech area of the brain at the timewhen the person says they are hearing voices. Thus, for practitioners, there is an important point: aperson hearing hallucinatory voices is not simply imagining something. A measurable experience isactually happening.

Delusions Delusions are false personal beliefs that are not subject to reason or evidence and are not explained by a person's usual cultural beliefs.

They make take a variety of forms. For example, about one-third of people with schizophrenia haveparanoid-type symptoms. These usually involve delusions of persecution, or false and irrational beliefs

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that they are being cheated, harassed, poisoned or are the subject of a conspiracy. These people often believe that a member of their family or someone close to them is making this happen.

Another form is delusions of grandeur in which the individual may believe they are a famous or important person.

Sometimes people’s delusions are quite bizarre. For example, believing that a neighbour is controllingtheir behaviour with magnetic waves; that people on television are directing special messages to them;or that their thoughts are being broadcast aloud to others. A person experiencing delusions may try to keep them secret, knowing that others would not understand. Other people can become overwhelmedand begin to act strangely in accordance with their delusions.

Negative symptoms

Negative symptoms are when the person experiences a degree of withdrawal from their normal life. For example, families may gradually realise that their relative's behaviour has been changing over aperiod of time in subtle ways. They may have become slower to think, talk and move, or indifferent to social contact. Their sleeping patterns may have changed so that they remain up all night and sleep all day. Body language may also be affected.

The overall result is a reduction of motivation, the effect of which varies from minor to severe. Negative symptoms are much less dramatic than positive, but they tend to be more persistent.

Recognising these changes can be particularly difficult if the illness develops during teenage years when it is quite acceptable for changes in behaviour to occur, particularly where the young person is experimenting with new freedoms and lifestyles.

Bipolar disorder/manic depression

Around one in 100 people experience bipolar disorder which is also known as manic depression.

The key symptoms are unusual shifts in mood, energy and ability to function. These are severe and quite different from the normal ups and downs of everyday life.

Bipolar disorder typically develops in late adolescence or early adulthood though it is frequently notrecognised until the symptoms become severe. It is often a long-term illness that must be carefullymanaged throughout a person’s life.

Many people have long periods between episodes when they are free of symptoms. About one thirdhave some residual symptoms and a small minority have unremitting symptoms. Symptoms of adepressive episode are described under “depression” above.

Some of the symptoms of a manic episode include:

• Increased energy, activity, restlessness• An overly high, euphoric mood• Extreme irritability• Racing thoughts and sometimes talking fast, jumping from one idea to another

• Reduction in the need for sleep• Unrealistic beliefs in abilities and powers

People with mania are more likely to use drugs, particularly cocaine, alcohol and sleeping medications.

Sometimes severe episodes of mania or depression include psychotic symptoms. These are described in more detail under the symptoms of schizophrenia.

Schizoaffective disorder

About one in every 200 people develops schizoaffective disorder although it is thought that this may be an underestimate.

The term is applied when symptoms of manic depression and symptoms of schizophrenia present at the same time (or within a few days of each other). Usually this diagnosis is given when thesymptoms of schizophrenia are more pronounced. Schizoaffective disorder usually begins in lateadolescence or early adulthood.

Personality disorders

Approximately 10-13% of the population has a personality disorder.

We are used to thinking of “personality” as the characteristics that make us unique. However, the term “personality disorder” is used when those personal characteristics cause someone to have regular and long term problems in the way they cope with life and interact with other people. There are different types of personality disorders. ‘The Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition (DSM-IV)’, identifies ten:

• Paranoid• Schizoid• Schizotypal• Antisocial• Borderline• Histrionic• Narcissistic• Dependent• Avoidant• Obsessive-compulsive

An individual may have more than one. However, it is likely that some people experiencing these problemswill never come into contact with mental health services. Others may easily be misdiagnosed – particularlybecause the symptoms may be more general than those of other mental disorders. In addition, somepeople may have other mental health conditions co-existing with personality disorders, but these are notalways diagnosed. ‘Co-existing problems of Mental Disorder and Substance Misuse (dual diagnosis) - anInformation Manual’ suggests that some personality disorders are more relevant to dual diagnosis thanothers. These include paranoid, schizoid, anti-social and borderline.

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The issue of diagnosis may become more complex where substance misuse is also involved. On the one hand, to achieve a diagnosis of personality disorder the person’s symptoms must not be as a result of drug or alcohol use. However, drug and alcohol dependence is often seen as a symptom of personality disorders.

When making a diagnosis, the criteria that a psychiatrist will look for may include the following:

• Symptoms have been present for an extended period of time. They are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder. The history of symptoms can usually be traced back to adolescence or at least early adulthood

• The symptoms have caused and continue to cause significant distress or negative consequences

• Problems are seen in at least two of the following areas:

• Thoughts (ways of looking at the world thinking about self or others, and interacting)• Emotions (appropriateness, intensity, and range of emotional functioning)• Interpersonal Functioning (relationships and interpersonal skills)• Impulse Control

Further discussion around personality disorders

In the past, some professionals thought that personality disorders were untreatable. Hence, commissioning ofservices has generally been poor or patchy. This has led to significant confusion and misunderstanding aboutthe disorder as well as to poor or patchy commissioning of services. In order to clarify understanding, wehave provided greater detail on the diagnosis and treatment of personality disorders. This information isintended to challenge myths about treatability and to alert practitioners to new guidance. It does nottherefore, imply that personality disorder is a special case in terms of treatment.

Treatment and services

A problem with services is that they have traditionally been focused on providing crisis and acute care. However, many people with personality disorders do not reach the threshold of crisis and may consequently not receive support. They may be living in an isolated way in the community withoutreceiving care and this can become a trigger for drug or alcohol use. However more recently, there have been advances in treatment and the Government has recently published guidelines: ‘Personality Disorder, no longer a diagnosis of exclusion’ (see page 69 for further details). Treatment may includemedication which is mainly used to calm anxiety and stabilise mood.

In addition, psychological approaches have been shown to be effective. These include cognitivebehavioural therapy (CBT) and also longer term psychotherapy. Another more specific form of therapy is Dialectical Behaviour Therapy (DBT) which is a longer-term form of CBT that has proved effective for some people with certain types of personality disorder.

Research1 has looked at the effectiveness of different approaches in different settings. This includespsychological treatments, drug treatments, service models and approaches, (including therapeuticcommunities) and features of good management.

Whilst there is increasing data on treatment, practitioners should be aware that there may be a shortage of services in their locality. Each area should now have a strategy for the treatment of people with personality disorders and it may be helpful to identify and work with relevant people.

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Engagement

It is particularly important to establish a good working relationship from the start. Many people withpersonality disorders may have had bad experiences of engaging with services and of not receivingappropriate support. This can lead to a vicious circle whereby they express their frustration and are thenregarded as “difficult” by services.

Working with symptoms

Personality disorders have traditionally been viewed in medical terms, and this presents challenges toservices which provide treatment based on medication. It is important to develop a better understandingfrom a psychological point of view, with an emphasis on changing behaviour. Try to look at the varioussymptoms and review whether they can be treated.

Making assumptions

Personality disorder remains a controversial diagnosis and an area where there is still much confusion. In particular, there is debate about the label “dangerous and severe personality disorder”. In practice,workers are unlikely to encounter clients with this label. It is a term used by the Home Office rather than a diagnosis given by psychiatrists. A tiny minority of people will receive this label, many of whom arealready in a special hospital or criminal justice system. It is important to avoid making assumptions.

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Section fiveIn practiceIn this section we look at issues and good practice around delivering services. This includes:

• The assessment process • Assessing and managing risk• Understanding and using the Care Programme Approach• Types of treatment offered by substance misuse services• Types of treatment offered by mental health services• Complementary therapies• Stages in treatment• Involving service users and carers in treatment• Meeting diverse needs including black and minority ethnic populations, women, gay, lesbian, bisexual

and transgender populations

The assessment processThis section considers the core principles involved in assessing a client’s needs and some of the issuesthat arise in practice. Some of these are particularly relevant to dual diagnosis and others are moregeneral. We then offer some suggestions for good practice.

Some core principles

Thorough, multi-disciplinary assessment is the first step towards providing an effective package of medical and social care.

Practitioners should aim to establish1: • The chronology of presenting problems• The relationship (if any) between them• Whether the disorders require independent treatment, or • Whether treating one will help alleviate the other

It is also important to gain an holistic picture of the client’s current lifestyle, domestic arrangements andhistorical factors relating to this.

This information should lead to a practical care plan that recognises a range of needs and wishes.

Some issues in practice

Preoccupations with “what came first”Many practitioners become preoccupied with establishing whether a person’s substance misuse is primaryor secondary to their mental health problem or vice versa. In a few instances, this may be clear, but as wehave seen, it is likely to be difficult to distinguish. There is a danger that answering this question, anddeciding which service should lead, will become the focus of an assessment instead of the client’s needs.

Unfortunately, the assessment often initiates a process of shunting the client between substance misuse or mental health services, with neither taking overall responsibility or co-ordinating care. In some cases,this shunting process is also linked to budgetary considerations or it may simply depend on which agency

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the client approached first. (Some of these issues are discussed further in the section on service deliveryon page 57). In other cases, access to mental health services may be difficult as some mental healthteams actively exclude people whose primary problem is drug or alcohol misuse.

Confusing symptomsThe symptoms of some psychiatric disorders can be very similar to the effects of substance misuse.

For example, it can be difficult to tell the difference between psychosis that is an ongoing mental healthproblem, and drug-induced psychosis that may disappear when the substance use is stopped. An extralayer of complication may occur if more entrenched problems have been caused by extreme or long-termsubstance misuse.

In practice, it may be that an initial diagnosis is made and then reviewed at a later date. However, even ifdetoxification may clarify the issue, appropriate treatment may not be available, there may be long waitinglists, or the client may be unwilling or unable to consider it.

Differences in culture between substance misuse and mental healthThere can be difficulties if the assessing psychiatrist feels that the client should be clean from substancemisuse before they can be properly assessed.

Awareness of holistic needsIn practice, assessments often concentrate on clinical needs and fail to address social needs suchhousing, employment, income or social networks. In fact, these factors are crucially relevant in terms of both the presenting problem and the treatment approach.

Clients and practitioners have different perspectivesThere are many reasons why a client may perceive their issues differently from a practitioner. Many peoplewith multiple needs have experienced social exclusion and/or trauma and their previous contact withservices may have been negative. For these and other reasons, they may not acknowledge the presence or extent of their difficulties, or they may not see their substance misuse or mental ill-health as a problem.

Practitioners should also be aware of the importance of cultural, spiritual and religious differences. These are discussed later in this section under ‘Meeting Diverse Needs’.

In addition, practitioners should be aware that stigma or the fear of stigma may act as a barrier toaccessing services.

Good practice suggestions for assessment

Consider the client’s concerns

Many people find it difficult to approach services and, in practice, many quickly disengage. From theclient’s perspective, the assessment can look as if it is for the benefit of the service rather than for them.The process can also seem intimidating.

It is important to be pragmatic. The key objective is to encourage the client to engage. This may meanthat the assessment does not take place on the first meeting but is delayed until the client has a betterunderstanding of what the service is offering. Or it may mean doing the assessment in stages so that it seems less intimidating. There is a balance to be struck between, on the one hand, ticking every boxand, on the other hand, ensuring that services have the depth of information they need to planappropriate referrals and treatment.

Consider a range of needs

It is vital to identify the range of a person’s needs for medical and social care. Practitioners shouldconsider issues such as the person’s domestic situation, food and shelter, access to primary care andchild care considerations. In practice, these issues have a huge effect not only on the problem but on the person’s ability and motivation to engage in treatment.

Avoid assumptions and keep an open mind

Try to avoid making hasty conclusions and do seek advice from senior colleagues when appropriate.Wherever possible, make your assessment on the basis of the client’s needs rather than on whatservices are available.

Timelines can be a useful tool

Moore and Rassool2 recommend the use of timelines. This involves noting the sequence of events for both substance misuse and mental health problems over a given time. This may be over a lifetime or a shorter period. Timelines can provide invaluable information and help indicate priorities for treatmentactions. This exercise should be done in partnership with the client to encourage them to make linksbetween issues in their lives.

Monitor regularly

Be aware of behaviour that gives cause for concern and regularly review the client’s progress. This isespecially important for clients with relapsing conditions. This may involve providing training for teammembers so that they are aware of signs of relapse.

Recognise positive achievements

Assessments often focus on weaknesses, deficits and risks and fail to acknowledge people’sachievements and strengths.

By recognising the positive you can help to build esteem, encourage engagement and also influencepeople’s coping strategies and treatment outcomes.

Factors that may influence a diagnosis

• The expertise/experience of the professional making the diagnosis• The definition of the psychiatric disorder3 that is used (professionals often disagree on this)• The perspective of the assessment team, (whether from a mental health or substance misuse perspective)• The population studied: for example, an urban situation where there is heavy substance use or

a population of successful professionals

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Assessing and managing risk “Staff see problems such as aggression and intoxication,

but they don’t often look beyond. Often that is the client’s only way of communicating – by being abrupt and aggressive.”

Nurse

It is important to have proper assessment and management of risk. This is not only to protect clients and workers but also because this is an area where there is significant ignorance, fear and stigma. If risk factors are simply ignored then hidden perceptions can hinder the treatment process.

Assessment of risk is essential for several reasons:• It helps to establish a consistent approach• It is key to the protection of the individual, professionals working with them and the wider community• It enables the individual, practitioner and other professionals to work more effectively together and

therefore helps to promote engagement

Some other factors to bear in mind in relation to risk include:Clients are more likely to pose risk to themselves than to others. Practitioners need to be aware of the risk of self-harm and attempted suicide.

Practitioners may fear that asking about ‘risky behaviours’ or suicidal feelings might encourage theindividual to engage in them. In fact, this is unlikely. Instead, by acknowledging people’s thoughts,practitioners can work with them using techniques such as anger management programmes, individualtherapy and group work.

For those with mental health problems, misuse of drugs or alcohol can contribute significantly to the risk of violence and disturbed behaviour. This is particularly true if misuse is combined with poor compliancewith medication or treatment programmes.

Research shows that people who have a dual diagnosis are more likely to have a history of violence than people with mental health problems who are not using substances. However the link betweensubstance misuse and violence is unclear but this may be due to disinhibition. The environment of misuse could also play a part since the illegality of many substances and associated crime may bringcloser links with violent behaviour.

It is important that the risk assessment looks at the individual rather than generalised risk factors.

It is helpful for services to work together to develop protocols that enable a shared approach to riskassessment and management.

If yours is a referral only service, you may need to complete a full assessment before the client can use theservice.

Include as part of the assessment process, a contingency plan for a deterioration in the client’s substancemisuse or a mental health crisis.

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Suggestions for good practice in risk assessment

Comprehensive assessments

Assessment should be systematic and thorough and may therefore take more than one appointment. It should consider four main elements:• Suicidal (or self-harming) ideas, plans and intentions• Ideas, thoughts and actions of harming other people• Self-neglect• Risks from others including exploitation

Threats to undertake violent acts either to self or others should always be taken seriously.

It is important to include past history as well as the client’s current situation.

Developing assessment tools

There is no one recommended risk assessment tool for people with co-existing mental health and substancemisuse problems. Therefore we recommend that practitioners look at existing tools in mental health andsubstance misuse and adapt them for this population. Some of the factors to consider include blood-borne viruses, compliance with medication and dangerous injecting techniques.

The importance of teamwork

This is essential both to support clients and workers. The ‘team’ should be multidisciplinary and shouldinclude relevant workers in a range of statutory and voluntary organisations.

For clients, such teamworking gives a greater sense of confidence that their multiple needs are being addressed. For staff, support is also important as the work is demanding and progress can often seem slow.

Clear lines of responsibility

When clear expectations and boundaries are established and communicated, this benefits all teammembers including the client. It also encourages compliance with treatment and medication.

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Information sharing and confidentiality

It is good practice to obtain consent from the client before sharing information. The client’s wishesshould only be overridden where there is a legal requirement, defined concerns about public interest or a serious risk to the client or others.

However practitioners should be aware that clients may be reluctant to permit information sharing. This may be because their drug use is illegal, or because they have had a previous negative experience of services, or even because of paranoia and anxiety relating to their psychological difficulties. In consequence it is important to treat these issues with sensitivity. Try to explain why information is shared ie to ensure that factual, relevant information is available to deliver the best possible care.Reassure the client that their privacy will be respected. Ensure that they have the information to whichthey are entitled.

The importance of information sharing cannot be over-emphasised when assessing future risk of an individual.

It may be useful to include family and friends in the list of possible sources of information.

You will need to have protocols for sharing information that should apply across a range of services and departments and in both the statutory and voluntary sectors.

For further information, see ‘Morgan S: Clinical Risk Management, A Clinical Tool and Practitioner Manual’ published by the Sainsbury Centre for Mental Health.

The Caldicott Report

The Department of Health’s ‘Caldicott Report (1997)’ identified weaknesses in the way parts of the NHS handled confidential patient data and so set out guidelines in order that:

1. Sharing of confidential information should be justified2. Confidential information should only be shared when absolutely necessary; 3. The minimum information should be shared 4. Access should be on a strictly need to know basis5. Everyone handling confidential information should be aware of their responsibilities6. Everyone involved should understand and comply with the law

The report also recommended that a senior manager/s within an organisation should take responsibilityto ensure patient data is kept secure and called this role a “Caldicott Guardian”.

At present, compliance with these guidelines is mandatory for NHS providers and local authorities andis good practice for other agencies in order to meet the requirements of the Data Protection Act (1998).

Practical advice about how to implement the Caldicott Guidelines and the use and protection of patientinformation is outlined in the ‘NHS Confidentiality Code of Practice (2003)’. More information is available from:www.dh.gov.uk/PolicyAndGuidance/InformationTechnology/PatientConfidentialityAndCaldicottGuardians/fs/en

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Regular reviews

The nature and likelihood of risk is not constant. It can be exacerbated by some factors, restrained byothers and can change over time. Therefore it is important to review assessments regularly - at leastevery 6 months and if possible, every 3 months.

Traditionally, reviews are often consultant led. However, it is increasingly recognised as good practice to carry out reviews in less clinical environments. For example substance misuse workers could attendreviews in out-patient departments, or mental health staff could go to substance misuse services orother community centres. It is also good practice for the client to attend.

Good quality documentation

It is essential that assessments, meetings and discussions about a client are recorded alongside careplans, and suicide prevention plans if appropriate. Other team members should know where this isstored in case of emergency. There should be at least a daily handover to update colleagues about eachclient in residential settings, where there are concerns about risk.

Staff training

All staff should receive training about risk assessment and management, at induction and on an ongoing basis.

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Understanding and using the Care ProgrammeApproachIt is important for practitioners in all relevant services to be aware of the Care Programme Approach (CPA). This provides the basic framework for ensuring that a range of agencies work effectively together to provide integrated packages of care.

The CPA was developed by the Department of Health and is the accepted framework for working withpeople with mental health needs. Its key provisions for inter-agency working are:

• A systematic assessment of health and social care needs• An agreed care plan, detailing responsibilities within the team • A care co-ordinator whose role includes keeping in touch with the service user and monitoring arrangements• A regular review (at least every 6 months), making changes as necessary. This may be more frequent,

depending on an individual circumstances, eg whether in-patient or out-patient

When using the CPA it is good practice to ensure that all parties have the relevant documentation. This means practitioners in all the services involved with the client. In addition, service users and theiridentified carers should also be given a summary copy of their CPA care plan. By law, services must applythe CPA to all the clients of working age who are accepted into mental health services. There are however,two levels of activity:

Enhanced – for those with severe mental illness with a high level of risk to themselves or others.Standard – for those who have lower level mental health problems or needs. Their care may be co-ordinated by the primary care team.

It should be noted that there is a similar framework within substance misuse. Models of Care (see page 36 for explanation) provides for Enhanced Care Co-ordination and Standard Care Co-ordination.

The CPA is a valuable framework and is effective when it is implemented, regularly reviewed and whenteams work well together.

In practice however, co-ordinating care between disparate agencies and across professional disciplinescan be problematic. People may have different professional views and it can be hard to co-ordinate diariesto get all the appropriate people together. Hence, reviews can sometimes be delayed.

In addition, when services are under pressure, clients who are on standard CPA may not be seen as apriority and so may not be seen as regularly as they should be by the team. Others clients may havesignificant needs but not fulfil the criteria for accessing support, or they may simply be undiagnosed.

In this way, many people with co-existing mental health and substance misuse problems can fall throughthe CPA net. Others, may technically be under the care of a psychiatrist or community psychiatric nurse(CPN), but may not actually engage with them.

If these people are in contact with services, it is more likely to be with voluntary sector agencies or housingagencies. In such situations, it is essential that casework is co-ordinated as much as possible with regularmeetings of all partners. If the person is not seeing a psychiatrist or CPN, it is important to find out if theyhave a key worker and what other support is available to them. This could include day services or crisisintervention, primary care and support from family and friends.

The key point to remember in practice is that, although CPA is the official mechanism for joint working, it may not always be in place. However, collaboration is still vital and should be pursued even if it is on a less formal basis.

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The role of the key worker

The concept of a key worker is central to both the CPA and Models of Care. This person may be thecentral co-ordinator of a package of care.

The key worker may be located in a range of agencies but the core task is to ensure that all involved inproviding a particular package of care understand their own roles, responsibilities and boundaries and howthese relate to the roles of other workers and agencies.

The core tasks of the key worker are to:

• Help to set realistic and achievable goals• Help to make best use of available assistance• Develop an integrated package of care and support• Promote the client’s independence & empowerment

This may involve liaison, sharing information, organising services, advocating, advising, supporting,handling conflict, writing reports and monitoring resources.

A carer’s perspective

John is a carer for his son, Philip who started using drugs in 1980 and was diagnosed with schizophrenia in 1984.

When Philip first started using drugs, it was four years before we realized there was an underlying mental health problem. The two issues were closely interlinked. I realized he was using drugs to counternot just the psychosis but also the effects of the medication he’d been given. He’d say, “I need somestuff after the medication – it makes me brain dead.” The medication would inhibit his dopamine levelsand slow him down so he would take amphetamines to speed up again.

I think it’s important that staff help carers to be more aware of the physical effects associated with dual diagnosis. That includes not just street drugs and medication but the physical effects of mentalillness such as reduced motivation and effects of substance misuse in terms of lack of appetite andenergy. This is really important in understanding someone’s behaviour and helping them to cope. For example, we used to make extra portions of our food, freeze them and then take them to Philipbecause otherwise he wouldn’t eat.

Another huge issue is support for carers in dealing with difficult behaviour. It can be very hard to manage a person who is on a short fuse, impulsive or even suicidal. Staff are experienced in handlingsuch situations but carers are given little advice.

Housing is also a big issue because of the stigmatising behaviour of mental health services. The figuresgive a very high prevalence for dual diagnosis yet few housing projects are prepared to take clients withmental health and substance misuse problems. Where are they meant to go? Often parents get caught upin subsidizing their housing and then find they are stuck with doing this as no-one else will pick up the tab.

I’ve been a carer for a long time. I’ve got used to hunting down the information I need on the web.However, services could do much more to involve us and use us as a resource. The reality is, we are an essential part of the care team.

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Care Planning Care planning is crucial to both the CPA and Models of Care.

A care plan sets out the essential steps in a person’s care and describes the expected treatment. Typically it is structured, multi-disciplinary, and task-oriented. It should always be developed with theactive participation of the client.

A care plan should include:• The treatment goals and milestones to be achieved• Treatment interventions specifying which agency and professional is responsible • A specification of how information will be shared: which information will be given to which agencies and

under what circumstances• An engagement plan – this is particularly for people who have found it difficult to engage with services• Consideration of any relevant issues relating to the client’s culture and ethnicity • A review date

The plan should also take account of any risk assessments.(Adapted from ‘Models of Care’ developed by The National Treatment Agency).

Person-centred PlanningWorkers often look at what services are available and try to fit the client into these. The idea behindperson-centred planning is to start with the client and their needs and wishes and to match these withwhat is available. It may include involving their family or friends where appropriate.

Being person-centred means:

• More than an exercise on paper, it’s a culture where clients come first • Considering how clients are involved in meetings about their own support, which may involve for

example, provision of advocates and or interpreters or changing the location or time of the meeting.Meetings should be informing and empowering for the client

• Ensuring that people’s personal histories are recorded in ways which are meaningful to them and their families. Regular staff changes, or a change in service provision should not mean that the process has to start again

• Considering funding streams which enable a person-centred approach, for example, direct payments

Summary of good practice recommendations

When a client is under CPA, reviews must be regular and multi-disciplinary.

Information should be kept up to date and circulated within the team.

A client and their identified carer should be given a summary copy of their CPA care plan.

Support systems should also be in place for those not under CPA, including contact with a key worker.

A care plan is central to CPA. This should also actively involve the client, and other professionals asnecessary and be regularly reviewed.

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Treatment

The value of treatment

Research has consistently found that there are clear benefits from treatment in terms of reduction, of drug use, abstinence and reduced criminal activity.

The evidence also shows that the faster the person gets into treatment, the more likely they are to stickwith it and hence to achieve a better outcome. In practice, the success of treatment will depend on anumber of other factors including the motivation of the person, the severity of their dependence andmental health problems, the extent to which their social care needs (eg housing, income) are met and the extent to which they have supportive social networks.

When considering the “success” of treatment, practitioners should be aware that there are a range of possible goals. Whilst abstinence may be an appropriate target for some, for others it may beunrealistic. Some other goals that may be appropriate include:

• Harm reduction: reducing the risks associated with drug taking. This includes both risks to the individualand to society. It could involve programmes such as supervised consumption, needle exchangesproviding clean works for injecting, programmes to address wider health needs such as reducing the risk of HIV or hepatitis

• Stabilising consumption. This is obviously helpful in its own right but may also enable people to meet the criteria for other treatment programmes

• Education: improving people’s awareness of risky behaviour, their understanding of any additional mental illness, their understanding of how the care system works and how to access support

• Addressing people’s social care needs and possibly some of the triggers for substance misuse

The most important factors to consider are: • Ensuring that treatment should address a broad range of needs including both health and social issues• Planning treatment on the actual needs and situation of the individual not following some abstract

preconception of “success”

Types of treatment offered by substance misuse servicesThe categories below describe broad approaches to treatment. Within each category there may be a number of specific service models.

Detoxification

The aim of detoxification is to eliminate substances from the body. It is often a gradual process and can involve the use of substitute medication to alleviate physical withdrawal symptoms. The substitute is usually given in progressively smaller amounts.

For opiate withdrawal, there are different types of medication. The most frequently used are methadone,Subutex, Britlofex or Naltrexone. Alcohol withdrawal is aided by benzodiazepines of which Librium is the most popular. Vitamins such as B complex can also help to aid physical recovery. For stimulant users there is currently no substitute medication that has been confirmed to be effective. Sometimesantipsychotics may be offered but in general, support focuses on approaches such as support,structured counselling, and additional complementary therapies (including acupuncture) as well as other health and nutrition programmes.

There are different types of detoxification programmes and services should review these in terms of theclient’s need. Factors to consider are the average amount of substances consumed, the length of timethe client has been dependent and their physiological and psychological condition. Variations intreatment may include the length of the programme and the setting – for example at home, in thecommunity or residential.

Detoxification should not be seen as complete in itself but as preparation for further treatment. Oncephysical dependence has been reduced, a client is likely to require ongoing support to address theeffects of psychological dependence and the issues underlying their misuse.

It may also be that detoxification enables services to assess underlying mental health problems and offer appropriate treatment.

Substitute prescribing

This is where a substitute prescribed drug is provided – usually under supervision. There are severalreasons why this may be done:

• To reduce and eventually stop misuse as described above• To stabilise use• To reduce the risks involved in drug use. For example, a prescription drug is a known quantity

whereas street drugs can vary widely in their purity and strength

Currently the most common substitute drug is methadone which is used for opiate dependence. It is generally provided in community settings with an accompanying package of support and therapy. A small number of doctors in the UK are licensed toto prescribe pharmaceutical heroin (diamorphine) for the management of dependence. Buprenorphine is also increasingly being used.

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Harm reduction

There is a range of interventions including education/advice and needle exchanges where people can obtain safe injecting equipment. This approach goes beyond drug and alcohol use and can also consider practical steps to address other issues in a person’s life – often through a care plan. This might include arranging housing appointments, debt counselling, and looking at wider health needs. The health needs might include considerations of risks arising from substance misuse such as HIV and Hepatitis as well as generic check ups.

Counselling and psychological treatments

There is a wide variety of talking treatments that are provided to both individuals and groups in a range of settings. These include individual counselling, group work therapy, structured day programmes,self-help groups (Narcotics Anonymous, Alcoholics Anonymous etc), outreach and drop-ins and criminaljustice interventions.

A range of approaches is also used in mental health services. These are described in more detail under ‘Mental Health Treatments’ on page 39-42.

Some talking treatments focus on enabling the client to explore their issues in a non-judgemental setting.Others will provide practical support to explore issues such as the underlying factors influencing substancemisuse and practical coping strategies that the client can adopt. Other aspects of counselling techniquesmay be used in assessing issues and needs (eg motivational interviewing as described on page 46).

Residential rehabilitation programmes

These programmes offer people the opportunity to leave their normal setting and live for a time in a safe, structured therapeutic environment. This can provide a valuable opportunity to maintainabstinence and improve health and lifestyle.

A short term programme may last between six and 12 weeks and may include detoxification as the firststage. A long-term programme may last between 12-52 weeks and does not usually provide detoxification.

Research demonstrates that residential treatment offers many benefits. However, “drop out” is alsocommon, particularly in the first two weeks. Unfortunately there is very little residential treatment available that is specifically geared to people with a dual diagnosis.

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Accessing Treatment for substance misuseSome services allow clients to refer themselves. Others require a referral from a service or professionalsuch as a GP, accident and emergency services, community drug projects, mental health professionals or through a number of criminal justice initiatives.

The underpinning framework for substance misuse is known as Models of Care. This groups services intofour levels or “tiers”. The table below, adapted from Models of Care, gives a summary of the tiers and theirmain referral routes.

Tier No.

1

2

3

4a

4b

Tier Title

Non-substancemisuse specificservices

Open accesssubstance misuse service

Structuredcommunity–based specialist drugmisuse services

Residentialsubstance misuse specificservices

Highly specialistnon-substancemisuse specificservices

Type of service, with examples

Work with a wide range of clients including those who misuse drugs or alcohol, but their solepurpose is not drug or alcohol treatment eg:

• Primary care• Housing services • A&E• General psychiatric services• General probation services

Provide drug and alcohol services described as low-threshold, often short-term eg:

• Drug related-advice and information• Open access or drop in services• Needle exchange, outreach services• Low-threshold prescribing• Drug misuse specific assessments and care

management

• Structured counselling and therapy• Structured day programmes and aftercare

programmes• Community based detoxes, and prescribing.

Treatment programmes for offenders

Aimed at those with high levels of need• In-patient drug detox and stabilisation services,

crisis centres• Substance misuse rehabilitation services• Services for people with co-existing mental

health and substance misuse disorders

Eg specialist psychiatric units and forensic services

Main routes of access

• Self-refer• Referred by

other agency

• Self-refer• Referred by

other agency

• Self-refer• Referred by

agency,primarily fromTier 2

• Self-refer(someinstances)

• Referred byspecialist,primarily fromTier 3

• Referred byspecialist, primarily fromTiers 2/4

Geoff’s story

Geoff is dependent on alcohol and has been using heroin for 23 years. He also has a diagnosis ofdepression. He has been in contact with many services over the years but for the last 15 years he hasbeen coming to the Kaleidoscope project in Kingston on Thames. This project offers a community basecombined with a range of services including methadone maintenance and reduction, needle exchangeand detoxification.

My wife and I were both drug addicts. We had four children and we lost them because of the drugs and the drink. The youngest are in care. My older son died four years ago. He had a girlfriend who gave him methadone and after three days he went to sleep and didn’t wake up. It was terrible – it still feels like yesterday. I’m also an alcoholic – my liver’s gone and I’ve got Hepatitis C.

I think Kaleidoscope is perfection. That’s a strong thing to say but I’ve been around a lot of services. This place is like my home. I come every day – it’s not exciting but it’s pleasurable to talk to people. You get your methadone and then go to the café. There’s lots of other people who have been coming for a long time. They all know me, they’re my friends. They ask about my kids – they’ve watched themgrow up. You have access to the medical staff if you want them but they don’t hassle you. They watchyou but from afar – it’s not in your face. The Hep C makes me sleepy. If I’m slumped over they wouldcome over and say - are you OK?

It’s like there’s this strong network of people – nurses, social workers, staff, other users. People treat you with respect. They are interested in what’s happening for you.

The dual diagnosis worker’s perspective

In many ways Kaleidoscope is unique. At the heart of it is the networking and sense of community. So many drug misusers have nothing to do and nowhere to go in the daytimes. Here the café is at thecentre of everything. People meet and talk and that helps us to informally keep an eye on how things are going as well as to deliver more formal interventions. As we see it, people need those kinds ofnetworks as a basis for working on the drugs.

Interventions via the criminal justice systemAs many substances are illegal, a significant number of people with co-existing mental health andsubstance misuse problems come into contact with the criminal justice system.

The Government’s ‘Updated Drug Strategy’ emphasises interventions at various stages of the criminaljustice system - from police custody, to courts and probation, prison and through care. The aim of theCriminal Justice Interventions Programme (CJIP), is to improve integration between different agencies and interventions so that clients receive beginning-to-end support.

There are a number of specific programmes that are relevant to this client group:

Diversion

It is government policy to 'divert' people with mental health problems who have become involved withthe criminal justice system to health and social services whenever this would be appropriate. This can be done at the police station, at the court, or from prison. If the person is detained under the MentalHealth Act, various sections of the Act enable a person to be diverted from the criminal justice system.(See Home Office Circulars 66/90 and 12/95 for further details.)

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Arrest Referral

Upon arrest, drug-misusing offenders are asked if they would like access to a drug worker who will thenencourage them to take up appropriate treatment. Participation is voluntary and it is not an alternative to prosecution or the due process of law. In some cases, offenders may be referred by the courts.

Drug Treatment and Testing Orders (DTTOs)

These are stand-alone community sentences available on the advice of probation officers and the court.The CJIP seeks to manage offenders as they pass through the criminal justice system. The CriminalJustice Act (2003) will create a single generic community sentence made up of specific elements whichwill replace all existing community sentences, including the DTTO. Sentences will be drawn from a ‘menu’of options, including different types and levels of drug treatment and can be tailored to meet theindividual needs of the offender.

Within DTTOs, attention has been restricted to criminal justice and substance misuse treatment systemsand has not adequately addressed ties with mental health care services. DTTOs have not anticipated thehigh proportion of offenders experiencing mental health problems. In practice, most areas have felt thatdrug users with mental health problems are unsuitable for a DTTO.

The National Audit Office's report ‘DTTOs, the Early Lessons, (2004)’ recommended that healthassessments for appropriate treatment might be considered for people with co-existing problems for whom DTTOs were not considered suitable.

Treatment in prisons

Intensive Treatment Programmes are designed for prisoners with moderate to severe drug misuseproblems and related offending behaviour.

Other prison-based services include voluntary drug testing and detoxification. These are available in all local and remand prisons.

The foundation of the prison drug treatment framework is the Counselling, Assessment, Referral, Advice and Through care (CARAT) services. These aim to meet the non-clinical needs of the greatmajority of prisoners and provide low threshold, low intensity and multidisciplinary interventions.

Through care is support for a drug misuser from the point of arrest to sentence and beyond. Aftercare is support after release from prison, or completion of a community sentence, or completion of treatment. This support should include help with housing, financial management, family relationships,learning new skills and employment.

Interventions via the Mental Health ActThe Mental Health Act can be used to provide compulsory assessment and treatment for peopleexperiencing mental illness and substance misuse problems. It cannot, however, be used for people whose only presenting problem is substance misuse. A number of civil sections can be used includingsections 2, 3, 4, and section 5 (see ‘The Mental Health Act 1983’ on page 83 of this toolkit). Treatmentprovided is primarily for the mental illness. When the criteria for admitting someone under a section are no longer fulfilled, the person cannot be held.

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Types of treatment offered by mental healthservicesIn general, medication plays a more significant role in mental health treatment than in substance misusetreatment. However, psychological and social approaches are also important, either on their own or inconjunction with medication. The key is to adopt an holistic approach that reflects clients’ needs such ashousing and occupation/employment.

Medication cannot cure mental illness but it is becoming increasingly successful at controlling symptoms.In the past, the action of medication has often been crude leaving people with many side effects. Whilstmany people still struggle with side effects, drugs have generally improved and there is a wider choice and fewer side effects.

Types of medicationThere are four main types of medication:

• Antipsychotics• Anti-depressants• Anxiolytics• Mood stabilisers

Antipsychotics

Antipsychotics are generally used to treat psychotic disorders such as schizophrenia, schizoaffectivedisorders and mania. They are sometimes used for psychotic depression or personality disorders or, in low doses, for people with severe anxiety disorders.

There are two types of antipsychotics: older typical and newer atypical. The older typical are the mostresearched and, until now, the most prescribed. Common side effects are sedation and movementdisorders. Important side-effects reported include tremors, shakiness and abnormal movements in limbs.These side effects can be disturbing, both for the person taking the drug and for others.

Newer atypical antipsychotics are better at treating the negative symptoms of psychotic illnesses and are less likely to induce movement disorders. The side effects recorded so far include weight gain, sexual problems, and diabetes.

Anti-depressants

Anti-depressants are used to treat depression and the depressive phases of manic depression. There are four types of anti-depressant:

• Tricyclic• Selective serotonin re-uptake inhibitors (SSRIs)• Mono-amine oxidase inhibitors (MAOIs)• Others

All of these work in a similar way to improve mood. However, they can have varying side effects.Common effects include dry mouth, sexual problems, drowsiness, weight gain and nausea.

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Anxiolytics

Anxiolytics are used to relieve anxiety. Benzodiazepines are the most frequently prescribed. The mostcommon side effects are drowsiness and dizziness. Anxiolytics are highly addictive and should only beprescribed for a short time for severe problems.

Mood stabilisers

Mood stabilisers are given to people with bipolar disorder, severe depression and some people withpersonality disorders. There has recently been an increase in the number of mood stabilising drugs though many of the old prescriptions are established as safe and effective. The side effects are different for each medication.

Types of psychosocial therapyThe benefits of “talking treatments” have long been recognised. These approaches are particularlyimportant for people with dual diagnosis where psychosocial problems may have led to mental illness or drug and alcohol use.

Approaches that are particularly relevant include: • Counselling• Cognitive therapy• Psychotherapy• Family intervention• Dialectical behavioural therapy• Art therapy• Drama therapy• Group therapy

Most of these approaches focus on talking and listening. However, art and drama are more practical and involve a creative approach to tackling difficult issues. Clients may benefit from receiving anassessment from a psychologist to decide which approach is most suitable.

Counselling

Some people may become confused because they wrongly think that ‘counselling’ is the generic term for all talking therapies. In fact, in this context, counselling is a specific intervention.

Counselling offers a space where clients can share their problems with a trained professional. A very basic distinction between counselling, cognitive approaches and psychotherapy is thatcounselling tends to be essentially supportive, cognitive tends to focus on practical problem solving, and psychotherapy tends to be more exploratory. In practice, the distinctions may be somewhat blurred and many therapists may use a range of strategies.

Counselling is offered in a wide variety of settings. It is characterised by being supportive, allowing theclient an opportunity to express their feelings and concerns without feeling either judged or directed. In this way, it seeks to empower clients to make their own decisions.

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Cognitive therapy

Cognitive therapy is a relatively short-term, focused and practical approach used for a range ofproblems. The focus is on how clients are thinking, behaving, and communicating today rather than on early childhood.

There are three commonly used approaches:

• Cognitive behaviour therapy• Cognitive analytic therapy• Dialectical behaviour therapy

Cognitive therapy is often provided by a psychologist but it can also be used by doctors, nurses,counsellors and social workers. Sessions are usually weekly and last for approximately an hour.

Psychotherapy

Psychotherapy tends to be more exploratory than cognitive therapy and is likely to probe more deeplyinto underlying issues. It provides a safe, formal and professional space where the client can exploredifficult, and often painful emotions and experiences such as anxiety, depression, trauma, or even theloss of meaning in life. Psychotherapy aims to help the individual to increase their capacity for choiceand become more autonomous and self determined. It may be provided for individual adults, children,couples, families or groups.

Psychotherapy is good for treating:

• Anxiety• Panic attacks• Emotional problems• Personality disorders• Stress• Insomnia• Depression• Bipolar disorder• Relationship problems• Psychological sexual problems

Psychotherapy is:

• An active process of participation • Offered within a set time frame – for each session and usually with an agreed number of sessions

in the first instance if it is offered in an NHS setting• Aimed at addressing current problems and also teaching problem solving skills• Aimed at reducing current symptoms and helping clients to prevent similar situations arising in future

Whilst psychotherapy is not always able to treat severe mental illness it can be helpful in:• Increasing compliance with medication• Enhancing social and occupational abilities• Improving ability to deal with stressors in society

• Decreasing denial and encouraging acceptance of the disorder• Decreasing the trauma associated with the disorder

There are a range of approaches within the broad heading of psychotherapy and more information canbe found at www.psychotherapy.org.uk

Family intervention

A family intervention is designed to help a client by bringing together family members, friends, co-workers and other supporters. Using a skilled and professional facilitator, the therapy can exploreissues, processes and needs in a dynamic, honest and supportive way. This intervention can be verysuccessful in encouraging the client to seek treatment.

Family interventions were originally developed to help families with a range of addictive problems. More recently, they have also been used to help families to cope with schizophrenia. Family interventionconsists of psycho-education, behavioural problem solving, family support and crisis management.Some interventions are conducted with one family, others may bring several families together. They vary in a number of ways – for example in including or excluding the patient, in the length of theintervention and accordingly to the severity of the problem being addressed.

Art therapy

Art therapy uses a range of media, images, creative processes and responses to the creative process.Through these, it seeks to illuminate the client’s development, abilities, personality, interests, concernsand conflicts. It can be powerful in helping clients to find different artistic ‘languages’ to understand and express their issues. The creative process is underpinned by a framework of developmental andpsychological theory. This draws on a wide range of counselling approaches.

Art therapy is used to treat a wide range of psychological issues. It is used for individuals, couples,families, groups and communities and with adults, children and adolescents. Art therapists are trained in both therapy and art and often work as part of clinical teams.

Drama therapy

Similarly to art therapy, drama therapy tries to give clients a different medium to explore and expresstheir issues. It is an active, experiential approach that helps clients to tell their story, express feelings,explore their inner life, build relationships and achieve personal growth. It also helps in relievingsymptoms, solving problems, setting goals, developing life skills and achieving resolution of conflicts.

Drama therapists are trained in theatre arts, psychology, psychotherapy and drama therapy.

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Complementary therapies Complementary therapies are used throughout the world to treat drug and alcohol dependence as part of an holistic package of care.

The most frequently used are auricular (ear) acupuncture, shiatsu and reflexology. There are no substitutedrugs for cocaine and cannabis and acupuncture is one of the few alternatives that most users accept. Although there is equivocal evidence supporting the specific effectiveness of acupuncture it is used forpeople dependent on opiates, cocaine/crack and alcohol. Clients report that the treatments help toalleviate anxiety, stress and physical pains, reduce substance cravings, promote relaxation, strengthenemotional and mental energy and aid sleep.

There has been little research into the effectiveness of complementary therapies in relation to dualdiagnosis. The limited literature focuses on acupuncture and less severe mental ill health. However, in addition to some of the benefits outlined above, people with mental health issues also say that theyenjoy the opportunity to relax in an holistic, rather than “medical” environment.

Complementary therapies also appear to play a valuable role in engaging clients and in sustaining contactwith services.

Stages in treatment of dual diagnosisWhilst all services could point to different phases in clients’ progress, the concept of having clearly defined stages in treatment is more common in substance misuse. The reasons for this go beyond thescope of this toolkit. However, in very general terms, it relates to the fact that people with substancemisuse problems may not see themselves as “ill” in the same way as people with a clearly medicalproblem such as cancer.

Hence, there is a need to positively reach out and engage with clients, and particular skills and techniquesassociated with different stages in treatment.

Osher and Kofoed (1989)1 have identified four stages in a long-term process that is particularly relevant topeople who have co-existing mental health and substance misuse problems. In practice, each person willbe different. They may move back and forward between stages and their progress from one to the otherwill vary. The four stages are:

• Engagement• Persuasion (Working towards change)• Active Treatment • Relapse Prevention

We will look at each of the four stages in turn and consider the ‘Cycle of Change’ and MotivationalInterviewing at Stage 2 (Persuasion).

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Stage one: engagement

Engagement has been described as forming a therapeutic alliance with a client. This first step is crucial to later stages in both achieving participation and ensuring that care is truly person-centred.

Practitioners should never underestimate the difficulties that clients can face in contacting services.Common problems are:

• Difficulty in acknowledging a substance misuse or mental health problem• The likelihood of increased stigma • Worries about disclosing confidential information – who will have access to it and how it may be used• Negative and sometimes traumatic experiences of services in the past. For example if a person with

mental health problems has been admitted to hospital against their will• Fears that children may be taken away by social services• A loss of control and concerns about the medication that may be used• Feeling intimidated by ‘the system’ with its numerous assessments. Doubting that “professionals” will

be willing or able to help

Traditionally substance misuse services have operated on the basis that it is the client’s responsibility to make contact with services and attend appointments and that this is a measure of their commitment to change.

However clients with co-existing mental health and substance misuse problems tend to find it difficult toengage with services. They have a history of “dropping out”, failing to keep appointments and not adheringto treatment programmes. Hence a more assertive approach is required. This may take some time andinvolve considerable persistence and patience.

Factors that promote engagement

The following guidelines will help to promote engagement:

• Motivate clients to see the benefits of the treatment process - this requires a clear idea of what theyneed and value

• Have a non-confrontational, empathic and committed approach • Offer help with meeting initial needs such as food, shelter, housing, clothing• Provide assistance with benefit entitlements• Provide assistance with legal matters• Involve family or carers wherever possible• Meet clients in settings where they feel safe. This may be more constructive than expecting them to

come to services

One model of engagement outlined in the ‘National Service Framework for Mental Health’ is the assertiveoutreach team. In this model, staff persistently and pro-actively contact patients.

Assertive outreach is commonly used to describe specialist teams with strict referral and operationalcriteria. However, features of assertive outreach are used by a broad range of professionals in other non-statutory settings. This may include home visits, or to getting to know family members and developing links with other agencies.

Many clients of assertive outreach services have dual diagnosis issues and these may be combined with other issues such as homelessness or contact with the criminal justice system.

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Case studies

The following case studies illustrate issues and practice around engagement and includeperspectives from service users and workers. They are drawn from a voluntary sector communityoutreach service that uses principles based on assertive outreach.

A is a client who is “anti professional”. She says she does not want or need any support. Staff have been successfully supporting her for over a year by “popping round” at various times and knocking on her door. A is very concerned about people coming into her home and rarely invites workers in in.However, she will usually engage in lengthy conversations on her doorstep. She will occasionally makecontact via card or letter. This is generally an indicator that she would like a visit, though the card neveractually asks for this.

B finds any social contact difficult as he would rather shut himself away and not “bother”. He will notanswer the telephone yet likes prior notice of visit times. As he often changes the time or day of a visit,this proved a block to working with him. After mutual discussion, it was agreed that “talking” betweenvisits should be via email. This is working well as B can contact staff at his pace and feels in control. The e-mails now often let workers know if he is feeling low, it also helps with his feelings of not wanting to talk at particular times as he can choose to e-mail at a time best for him.

Initially, C did not welcome or recognize the value of ‘social’ support. He felt if the doctors couldn't doany more for him then he wouldn't get any better and just had to put up with his illness. At first he oftencancelled visits but gradually over several months, with persistence and long conversations about thebenefits of being able to get out, he is now able to meet others and actual talks at meetings about thebenefits of outreach work in the voluntary sector.

Stage two: working towards change/persuasion

This stage is about building motivation and working towards change. In this section, we discuss twohelpful approaches that are widely used in substance misuse.

The Cycle of Change

This makes the point that change is not an instant decision but rather one which involves a person going through a number of stages. The model helpspractitioners to see what stage the client has reached and their readiness tochange and to adjust the treatment accordingly.

Pre-contemplation: before the individual has recognised the need for change.Contemplation: the individual recognises the problem and considers doing something about it. However, there is still ambivalence about change.Decision: actually decides to do something about the problem behaviour.Active change: the individual attempts to change the behaviour by seeking outside help (treatment).Maintenance: the individual tries to maintain the changes made.Relapse: a return to the levels of activity before treatment.

Pre-contemplation

Relapse

Maintenance

Active Change

Decision

Contemplation

Prochaska and Diclemente (1983)

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Motivational Interviewing

This is a form of counselling that aims to change behaviour. It is often used by specialist therapists.However, practitioners at all levels will find the approach helpful.

It involves presenting factual information in a non-judgmental way and inviting the client to give their views. The facts might include both standard statistics and personal data. For example, the general effects of substance misuse on mental health and specific results of the person’s urine analysis.

The practitioner takes the role of an active listener who reflects back the client’s responses. In this way, the client is helped to see aspects of their life that are problematic and how the use of substancesexacerbates their difficulties.

There are five general principles:

• Express empathyAcceptance facilitates changeSkillful reflective listening is essentialAmbivalence is normal

• Develop discrepancyAwareness of consequences is importantA discrepancy between present behaviour and important goals will motivate changeThe client should present the arguments for change

• Avoid argumentsArguments are counterproductiveDefending breeds defensivenessResistance is a signal to change strategiesLabelling is unnecessary

• Roll with resistanceMomentum can be used to good advantagePerceptions can be shiftedNew perspectives are invited but not imposedThe client is a valuable resource in finding solutions to problems

• Support self efficacyBelief in the possibility of change is an important motivatorThe client is responsible for choosing and carrying out personal changeThere is hope in the range of alternative approaches available

Potential interviewer errors:• Question-answer trap• Confrontational-denial trap• The expert trap (offering your solutions)• The labelling trap• Premature focus trap• The blaming trap

Five early strategies:• Ask open ended questions• Listen reflectively• Affirm• Summarise• Elicit self motivational statements:

problem recognitionexpressions of concernintentions to changeoptimism about change

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Stage three: active treatment

At this stage, the client is persuaded of the benefits of treatment and works with a range of practitioners to achieve agreed goals. It is important that the client is actively involved rather than a passive recipientand that the inputs of a range of care agencies is co-ordinated.

Factors involved in active treatments

Continuous assessmentFrequent reviews of progress and interventions are important. If a person is not engaging with a particularaspect of treatment, it may be better to re-visit this at a later stage.

Setting goalsThese should be: • Negotiated – reflecting both the professional judgement of the treatment team and the client’s

perspective and commitment • Clear and measurable • Realistic – avoid being over-ambitious• Broken down into short-term targets to encourage a sense of achievement

In considering goals, it is important to include two broad areas: • Enhancing people’s coping skills• Building their social skills and networks

Education and awarenessIt is important that clients understand what their diagnosis means and are informed about the medicationthey are taking. This includes what it does, side-effects, contraindications with other substances they areusing and effects on mental health. Practitioners should be aware that many clients lack this informationand may feel unable to ask their psychiatrist.

Clients should be included in discussions and should be supported in developing questions to take to their next appointment. In this way they can feel more confident and involved in their care. Access toindependent advocacy may be helpful.

Psychological interventions can also play a valuable role in education and can help a person to understandtheir situation and choices.

The following table illustrates areas where the interviewer can easily go wrong and suggests somepractical solutions.

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Stage four: relapse prevention and management

Relapse should be anticipated in both substance misuse and mental illness. However, it is important thatboth the worker and client see this as an opportunity to learn and to develop preventative strategies.

Clients can be helped to identify situations in which they will become vulnerable to substance misuse or mental distress and can agree actions they will take in response. For example, if a person experiencesanxiety around social interactions they may be helped by anxiety management or social skills training.

Other interventions that may be helpful include cognitive behavioural therapy, assertiveness training andrelaxation techniques. In addition, meaningful activity is also very important. This might include voluntary or paid work, sport or hobbies. Such activities offer alternatives to usual patterns and can help to developnew social networks.

Factors involved in relapse prevention:

Identify high risk situationsThis involves monitoring early warning signs and developing coping strategies.

Access to servicesThis may involve reviewing opening hours, considering crisis intervention and how mental health servicescan provide long term continuity of care.

Considering social factorsFor example, housing, family and social situation.

Considering routinesLooking at whether a change of routine could be helpful – for example through education, voluntary workor leisure activities.

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Involving service users, families and carers in treatment

“Involving service users and their carers in their treatment and in service development is not an optional extra. The expert

knowledge which they bring is a vital part of the resources which any service planners must have at their disposal.”

Treated as People, SSI (2004)

Much of this toolkit has stressed the importance of partnership working between many agencies anddifferent disciplines. Equally crucial is the role and involvement of the client and, where appropriate, their families and carers. Involvement should take places at all stages:

In treatmentThis includes working with practitioners on short-term and long-term goals, and being present at reviewand other important meetings.

In the planning, delivery and development of existing servicesViews can be expressed through a variety of ways, for example “suggestion boxes” at services, serviceuser representatives, patient surveys or user forums.

In the planning and commissioning of future servicesThis is usually on a more formal level by consultation or involvement as part of a planning group.

Within services, the extent to which users are involved will vary. Some organisations are run by and forusers. Others work in partnership with clients or describe themselves as working on behalf of clients.

The key point is that participation must be genuine and not tokenistic or superficial.

This is an important subject and beyond the scope of this toolkit to cover in depth. However some briefcore principles include:

• Ensuring that relevant information is accessible and provided in user-friendly formats and languages• Providing access to independent advocacy where appropriate. This should ensure that people

understand their treatment and available options and are able to express opinions and preferences • Making adequate resources available to support users. This could include both “human resources”

such as facilitators or translators, and finance to cover transport and other expenses • Giving regular feedback on actions suggested by users so that they know their views are taken seriously• Encouraging users to participate. It is important that users are clear about why and how they will be

involved and how this may affect outcomes• Developing a culture that recognises and encourages the rights of service users to participate as fully

as possible in decisions about their care and evaluate the services they receive

Meeting diverse needsIn principle, if care were truly person-centred then it would not be necessary to include chapters ondiversity. In practice, it is useful to be aware that there are broad groups of people whose needs are not always appreciated or met within current services. In this section, we focus on three broad areas of diversity:

• Black and minority ethnic groups• Women• Gay, lesbian and transgender issues

Black and Minority Ethnic Groups Although there are some local studies, data on substance misuse among ethnic minorities in the UK is sparse, and there is a danger of making estimations and broad generalisations.

The special issues relating to members minority ethnic groups with mental health problems are well known.A recent inquiry into the death of David Bennett (2004)1 highlighted many of the problems:

• Misdiagnosis. For example, a disproportionate number of people from non-white ethnic groups are givena diagnosis of schizophrenia. In addition, psychiatrists can sometimes attribute mental health conditionsto “drug induced psychosis”. In Afro-Caribbean communities this often relates to the use of cannabis

• Institutional racism• Disproportionate detention under the Mental Health Act• The prevalent use of restraint• Over-reliance on medication and less access to talking treatments

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Good Practice Recommendations

Avoid making assumptions

It is easy to make assumptions around gender, race or sexuality, and create stereotypes, which cancloud our judgments. Minority ethnic communities are themselves diverse, each with distinct identitiesand with different ideas about both mental health and substance misuse.

Develop cultural awareness

Psychiatry was developed by white, male Europeans, and diagnoses can reflect this. Standard means of expression in one culture may be misinterpreted in another, perhaps leading to misdiagnosis.For example, people from some Asian cultures may look down as a sign of respect, which could bemisinterpreted as shyness or evasiveness. People from an African or Afro-Caribbean culture may look at and speak to their listener directly, which could be misinterpreted as being aggressive.

Develop understanding of other models of health and illness

Different cultures will have different models of health and wellbeing and a variety of approaches totreatment. For example, some cultures have a more holistic approach in which there is less distinctionbetween the person and the disease or between medicine and religion.

Whilst not abandoning European approaches, it is important to explore the client’s understanding and beliefs and to address issues that they see as relevant to their psychological health.

In some cultures people will describe their psychological state in terms of physical symptoms, e.g. in some Asian cultures depression might be described as a chest pain. It may take carefulquestioning to separate the mental health problem from any medical problems.

Be aware of stigma

Many people with mental health and substance misuse issues experience stigma and feelings of shame and isolation but this can be more severe for people from ethnic minority communities. In addition to racism and exclusion within the wider community, there may also be stigma within their own community.

For refugees and immigrants, there may be barriers to working with UK services. For example, services may be seen as intimidating or alien and it may be culturally difficult to ask for help outside the family or community.

There is a need to match the type of contact to meet the needs of different clients.

Recognise generational issues

The experience of people who were born in the UK will be different to elders who were immigrants. For example, first generation immigrants potentially face huge changes in financial and social status and family role. Their children however, may face cultural or identity conflicts and tensions in theirposition as carer or interpreter for their parents.

Understand differences in substance use

Substances and methods of use vary between different ethnic groups. For example, injecting is seen as ‘dirty’ and injectors are ‘junkies’, among people from the African and Afro-Caribbean communitieswho have historically tended to smoke and pipe drugs.

People from ethnic minorities may use drugs or alcohol with other members of their cultural and ethnicorigin to re-establish a sense of community and to help overcome isolation and marginalisation. Somedrugs have a cultural significance - for example, khat chewing among members of the Somali, Yemeniand Ethiopian communities. Practices and patterns can be very regional.

There are also significant differences of use between men and women. For example, women may misuse in the home because they rarely go out and feel socially isolated.

Making services more culturally appropriate

The workforceThere is a perception that services are run for and by white people. Ideally mental health and substancemisuse teams should reflect the cultural and ethnic diversity in their local area. Strategies should be inplace to recruit, retain and promote qualified and ethnically diverse staff at all levels.

It is also important to recognise and address racism where it exists. All staff should receive ongoingtraining in cultural awareness.

The range of treatment offeredSome services have a “European focus” with emphasis on prescribing and appointments. Treatment ismuch more than this and should offer a broad menu of options to meet the wide range of identified needs.In addition to psychological therapies, social support and access to ancillary services, complementarytherapies such as acupuncture, aromatherapy, massage, hypnotherapy and meditation are found to behelpful. These have benefits to all clients, but can be particularly attractive to black and minority ethnicgroups, for whom such treatments are more commonplace.

The delivery of servicesTo help overcome stigma, many agencies working with black or Asian clients provide services throughtelephone counselling. Others will see clients away from their home area. It is also important to considergender specific services, especially for Asian clients. Other measures to consider include: different openingtimes, satellite clinics, clinics in other healthcare/community settings. Where possible, attention should begiven to the décor of waiting areas and counselling rooms. Services should be developed in consultationwith local communities to establish effective access and a suitable environment.

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WomenThere are significant differences between men and women in relation to dual diagnosis. These apply to both the nature of their problems and the way in which they present to services. The needs of women and the implications for services are briefly considered below.

Childhood abuse

Women who misuse substances are significantly more likely than other women (or men) to haveexperienced sexual, physical and/or emotional abuse as children. It is important that these issues are addressed and also that there is greater provision of women only services where appropriate.

Physical violence

Rates of domestic violence amongst women are high. Refuge estimates that one in four women experiencedomestic violence at some point in their lives. Therefore it is important to consider provision of alternative,secure accommodation.

Medical illness

It has been shown that women with co-existing problems also have high rates of medical illness(Brunette 971) and practitioners should be alert to these needs.

Issues around engaging with services

It is known that fewer women present to services than men. However, this may only be partially due to a lower prevalence of dual diagnosis. It could be that women are not seeking help or that services are not appropriate for their needs (Crome 972). Women are more likely to present at mental health orprimary care services and to refer to psychological difficulties rather than substance misuse problems.Some of the barriers to accessing help may be:

• Male dominated provision, with few women-only services or facilities for child care• Poor knowledge amongst staff about child protection issues• Weak links with social services which can lead to uncoordinated and poorly planned joint working • Fear that children will be taken into care• Childcare responsibilities may make it difficult to attend appointments• Stigma

Good practice recommendations

• Better training about the particular issues faced by women• Expansion of designated sessions and women only services • Recruitment of more female staff

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Lesbian, Gay, Bisexual and Transgender issuesThere are a number of issues which are particularly relevant to lesbian, gay, bisexual and transgender(LGBT) communities. It is important to understand some of the extra pressures that some LGBT peoplemay face and how these can impact upon a single, or dual, diagnosis.

Internal pressures

LGBT people face an internal pressure to identify their sexual orientation or gender difference tothemselves before discovering whether they are able to accept this difference. Then there is pressurearound whether to “come out” and publicly declare their difference. Not to do so may result ininternalising the situation, leading to depression, low self-esteem or self harm, whilst “coming out”, may open the person to increased discrimination, homophobia or hate crime.

Stigma

Misunderstanding and stigma, reinforced through negative media and discrimination, can lead people to adopt various coping mechanisms. These can include drug and alcohol use or engagement incompulsive or risky sex. Living a “double life” is still common – for example, being out with a group of friends but not at work.

Psychological distress and/or substance misuse

It is important to treat everyone as individuals and to avoid making assumptions. However, a report1

published in 2003 by Mind drew similar conclusions to US reports in finding that (in their sample) gaymen and lesbians reported more psychological distress than heterosexuals. This was despite similarlevels of social support and quality of physical health. The same report, (and others), discovered higherlevels of substance misuse among lesbians and gay men than amongst heterosexuals. Many findings are collated in a scoping study2 for the Home Office downloadable from the www.drugs.gov.uk website.

Engagement with services

Of further concern are the experiences of some members of the LGBT community within services.Among lesbian and gay individuals, the Mind report highlights a reported lack of empathy and rapport by practitioners. This can impact on a service user’s choice about accessing services at all for fear ofactual or perceived homophobia. There may also be fears around levels of disclosure, engagement andsuccess should they choose to attend.

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Good practice recommendations

Prioritise increased awareness of LGBT issues

This can be both within services or by personal research. Training should include the possible links between sexual orientation and mental wellbeing, and the increased risk of substance misuse within some LGBT communities.

Proactive sharing of good practice

Agencies should pro-actively seek to share good practice and work in partnership with specialist LGBT organisations. The experience and opinions of LGBT service users should be monitored. Targetedinterventions and campaigns should then be considered to address any gaps in access to treatment.

Include LGBT issues in organisational policy

Organisations should ensure their policies include awareness of differing needs of people from LGBTcommunities and consider monitoring sexual orientation at assessment or triage stage.

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Section sixStructures

Service Delivery“People with a dual diagnosis, are in effect, a kind of mental health

underclass. They find that their needs are not severe enough to meet the criteria of any single agency, so they can just fall below the threshold of all the ‘helping’ services. For example, they may have mild ideas of suspicion

but may not be clearly psychotic. They may have been to prison but not long enough to be followed up by probation. They may have been squatting with

friends, but not technically homeless. There may be no clear reason why social services should allocate a social worker. As a result, they have

a dreadful quality of life, even though they may have six or seven major problems, they may receive either no help, or just bits

and bobs of help without clear co-ordination.”Psychiatrist

Although this toolkit is focused on practical issues, there are also underlying issues around the structureand culture of services that have a significant impact on both workers and clients. Therefore, in thissection we consider:

• The challenges of delivering an holistic approach• Some ideas for better integration between services • Identifying and meeting training needs• Some good practice examples

The challenges of delivering an holistic approach

The basic underlying principle of supporting people with a dual diagnosis needs to be client-centred.This produces challenges at all levels - from strategic, to operational planning, to delivery at the front line.These challenges arise because most clients have a range of issues including physical health and socialcare needs. Whilst it can be easy to talk about the concept of holistic care, in practice it can be difficult to co-ordinate inputs across many disparate services with their own cultures and policy frameworks. Wehave already seen that there are problems in joint working between mental health and substance misuse.However, a truly holistic approach would also need to involve social services and a range of providers inboth the statutory and voluntary sectors.

In this section we look at some of the issues around social care. We then consider issues between mentalhealth and substance misuse.

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Social careIn practice, it is often the social issues such as poverty, unemployment, housing and social isolation thathave the greatest impact on a person’s ability to engage with treatment. For example, housing is a majorissue. Those who are homeless or have insecure housing tend to have greater difficulties in attendingappointments and taking medication regularly. They may also suffer social isolation that exacerbates theirmental health problems and increases their vulnerability to substance misuse and poor general health.

One study shows that homeless people with mental illness and substance dependency were five timesmore likely to lose contact with caring agencies as those who were not similarly dependent. Conversely,suitable housing can bring about increased stability, an improvement in engagement and treatmentoutcomes, promote recovery, lessen the likelihood of relapse and encourage social interaction.

Sadly, there is a huge shortfall in supported housing for many vulnerable groups and those with complexor multiple needs can find it extremely difficult to access and maintain suitable accommodation.

“Dual diagnosis patients are often the bed blockers – no-one will take them after hospital. Services like housing and day centres shy away.

They want people who are drug-free.”Mental health nurse

A wide range of other social factors may also be relevant to this client group. The illegal nature of somedrug taking may lead to a criminal record, which in turn makes it hard to find a job or meaningful daytimeactivity. People may become socially isolated and lose contact with friends or relatives. Poverty andproblems with benefits can lead to rent arrears and then put housing in jeopardy. On top of this, peoplefrom ethnic minorities can face a range of cultural barriers.

Issues between health and substance misuse services

“Dual diagnosis clients are everybody’s business, but nobody’s priority. Substance misuse and mental health are two parallel universes

with totally different cultures and commissioning practices.”Clinician and researcher

“There seem to be two conflicting models at work here. In mental health services, people can be seen as sick, their responsibility is taken away from them and gradually they become reliant on the services. In

substance misuse services, current thinking is that people need to takeresponsibility for their own drug use and the problems that has brought on.

These two models don’t really come together. If you’re the client in the middle of this, you may be receiving very contradictory messages”.

Clinician and researcher

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There is a range of issues at both a strategic and operational level:

• Substance misuse and mental health operate differentlyAlthough there is some joint thinking at a strategic and commissioning level, the two services stillfunction differently at a planning, funding and operational level. This means that people with multipleneeds are often passed from one service to another or fall through the gaps completely. A recent study by Turning Point and the IPPR ‘Meeting Complex needs, The Future of Social Care, 2004’ has highlighted that, although the commissioning process has four distinct elements: assessment, planning, commissioning and monitoring, all four are rarely fulfiled.

• Different cultures/ideologiesAlthough practice varies, substance misuse and mental health services are based around differenttreatment philosophies and so have developed in very different ways.

Substance misuse services place more emphasis on a psycho-social perspective and offer treatmentbased on these ideas. It is generally necessary for the service user to be motivated and capable ofengaging in treatment. Mental health services often adopt a more medical model of treatment and,if necessary, have powers under the Mental Health Act to provide treatment to an individual, even if they do not wish it.

It is understandable that these different ideologies translate into different ways of operating. For example,Community Psychiatric Nurses are based in the locality and visit people in their homes whilst mostsubstance misuse services tend to expect a client to attend an appointment.

• Rigid professional boundaries and lack of trainingPractitioners in either field may regard this client group as outside their professional remit. They may feel they lack the necessary understanding, skills or resources or that they have not received appropriatetraining. Others may feel that their particular specialism is being challenged. There will always be a needfor specific and distinct skills, but this should not preclude collaboration with other practitioners.

• Lack of clarity about roles and responsibilitiesThis can lead either to a duplication of work (for example with assessments) or a failure to takeappropriate action.

• Pessimism about outcomesPeople who have co-existing needs are undoubtedly challenging to work with. Several studies havefound poor records of compliance with treatment and worsening of psychiatric symptoms in comparisonwith people who have a single diagnosis.

It is important to recognise these factors. However practitioners should note that the difficulties might ariseprecisely because multiple needs cross professional structures. Hence the problems may arise from theservices rather than the individual. Other studies have shown that treatment and care does work for thisclient group.

“People in mental health can see people’s continuing use of drugs as sabotaging the care they are receiving. They forget to

ask the reasons why people start or relapse.”Worker in substance misuse

“We need to have realistic goals for ourselves just as much as for clients.Sometimes it feels like taking down a wall with a teaspoon. We need to

remember that change can happen even if can take years.”Dual diagnosis trainer

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Ideas for better integration between servicesGreater integration needs to be approached at both a strategic policy level and in terms of operatingstructures and practices on the ground.

Strategic level

• Links between government policies: For example, it would be helpful to link the current work of separatedepartments on social exclusion and mental health, guidance on personality disorders, delivery ofservices to people from different ethnic groups and changes to the Supporting People framework. TheSocial Exclusion Unit at the Office of the Deputy Prime Minister has made some encouraging moves inthis direction as has the development of the National Institute for Mental Health in England (NIMHE)

• Co-ordinating commissioning and planning: It is essential that those planning, commissioning anddelivering services are clear about the nature and extent of need. There is a need to develop clearcommissioning protocols that promote co-ordinated care. At the same time, these processes need to be flexible to recognise local need and to identify which agency is best placed to provide which servicein a given area

• Promoting mutual understanding: practitioners can do much here to understand what different servicesdo, how to access and refer, set up systems and processes for interagency working and ensure thatcase working across agencies is working effectively. (The Networking Tool provided as part of this packis intended to support practitioners in this process. See page 1 for details of how to order.)Informal networking between practitioners can also be extremely useful in building relationships andunderstanding

“What would be helpful is to share good practice about service development. There’s the high-level policy advice and now some guidelines about working with individuals. The gap is – how have different services put

the policy into practice? What works best in different areas? And, importantly,what hasn’t worked. I often wish we had more courage to be honest

about what doesn’t work and then we could learn from that.”Worker in mental health

Operational level

This section looks specifically at opportunities for greater integration between substance misuse andmental health.

The Department of Health’s ‘Dual Diagnosis Good Practice Guide’ states that the primary responsibility for the treatment of individuals with severe mental illness and problematic substance misuse lies withmental health services. It describes three current models of service delivery in the UK:

• The serial model: “implies treatment of one condition before the other”• The parallel model: “implies concurrent, but separate treatment of both conditions (by different teams)”• The integrated model: “implies the concurrent provision of both psychiatric and substance misuse

interventions but requires the same staff member or clinical team working in a single setting to providerelevant psychiatric and substance misuse interventions in a co-ordinated fashion”

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The favoured approach is to work towards the integrated model. Services are recommended to agree a definition of dual diagnosis based on local need and to use this to guide service development.

There are several possible service models:

• Dedicated dual diagnosis teamsIn this model, all workers receive specialist training and lead the provision of dual diagnosis care. Whilstthis is recommended in some circumstances, there can be difficulties. The model may be too expensiveand too specialised to address a range of issues. Some people may be excluded because they do notmeet the strict criteria for access.

At the same time, there can be problems with heavy caseloads and staff burnout. This is particularly trueif there are unrealistic expectations that this team should be responsible for all dual diagnosis clients.

• Training of specialist dual diagnosis workersHere the specialists would be placed within generic services and would spread expertise about dualdiagnosis issues.

• Networks of clinicians with expertise in dual diagnosis issuesThese would be placed within teams where there are high levels of need.

The choice of model will depend on service structures and situation locally. Every model has benefitsand disadvantages.

• Case ManagementWhatever model is used, effective caseworking is central and this needs skilled caseworkers withcapped caseloads1.

As Checinski2

points out, whatever model is chosen, some individuals will not fit into it. Therefore it isimportant to have a strong keyworker system to broker a range of care. He sees this as a “virtual team”with a client and keyworker at the centre and a network of relevant agencies around them. Dependingon the needs of the individual, this might include mental health nursing, substance misuse teams,psychiatry, clinical psychology, the primary care trust and the local authority providing housing andeducation. Checinski concedes that this has the advantage of flexibility, but not the cohesion of a“physical team”.

Good practice recommendations

Map existing service provision and agencies

A wide range of additional agencies may be relevant to this client group including A&E, social services,primary care, housing associations, police, probation and other criminal justice agencies, specialistagencies working with diverse issues. It is recommended that a dual diagnosis steering group be formedto map out the full range of possible services. (A Networking (mapping) Tool is provided in associationwith this toolkit. Please see page 1 for details of how to order this.)

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Good liaison and partnership between agencies

It is important to build relationships with a range of services, to understand their referral criteria and thecare and support they provide. It is essential that practitioners are aware of acute inpatient services aswell as those based in the community.

“Informing other professionals about what services are on offer, where they are based and how to refer can be as valuable as drug and alcohol awareness.”

Senior Team Leader, Community Drug Project

Multi-agency approach

This requires joint ownership of goals as well as clarity about the roles and responsibilities of eachagency. An agreed care plan is central to this approach (see page 30 on the ‘Care ProgrammeApproach’). It is important that the treatment goals agreed for each individual are clarified betweenagencies and that they are felt to be realistic.

Issues to be covered by inter-agency protocols

• What each agency does and can offer for the client group• Common assessment tools and procedures• Agreed care pathways, including referral arrangements, assessments, service provision and

arrangements for discharge from hospital or prison• Confidentiality/data sharing• Standardised data collection• Discharge arrangements for all services• Joint training plans• Risk assessment

Pathways for referral

When the joint working as described above is still not able to support a particular individual, there should be a clear pathway for referral to more appropriate agencies.

Clear plan for ongoing care

An agreed strategy for continuing care is important in minimising relapse and maximising outcomes.

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Identifying and meeting training needs“Yes, we need skills training but we also need to work on changing

staff attitudes. People in substance misuse are reluctant to work with “mad” people and people in mental health are nervous about working with

substance misuses. Actually there are strong parallels with client work – we need to listen empathetically, to understand what workers are afraid of,

what the barriers are and roll with that resistance. Just as with clients, one session won’t do it – it will need time and ongoing support.”

Dual diagnosis trainer

“We urgently need more dual diagnosis specialists on the wards to bridge the knowledge gaps. The levels of skills and knowledge are very low.”

Dual diagnosis nurse

The Department of Health’s ‘Dual Diagnosis Good Practice Guide’ recommends that services undertake an audit of training needs. It also suggests core competencies that are relevant to all staff in all settings.These are:

• Knowledge of dual diagnosis• Drug and alcohol awareness• Assessment skills for substance misuse• Assessment skills for mental health problems• Risk assessment and management• Knowledge of the management of substance misuse problems• Knowledge of the management of mental health problems• Engagement skills• Care co-ordination• Motivational enhancement strategies including Motivational Interviewing• Relapse prevention for substance misuse• Early warning sign monitoring and relapse prevention for mental health problems• Mental health legislation

Training should be based on case discussion and debate that is relevant to the particular team’s workingpractice. Wherever possible, services should promote internal sharing of information and expertise.

There should be an ongoing rolling programme to ensure that training is informed by the most recentresearch.

Ongoing supervision and continuing professional development is vital. Peer support networks andincreased joint training can help to achieve this.

Given the issues discussed above in relation to culture, it is important that training addresses attitudes and perceptions as well as practical skills.

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Training in relation to client need

The CASA Multiple Needs Service (MNS) suggests relating the need for specialist training to levels of clientneed. It outlines three levels of need:

• People with coexisting needs who would be able to use existing (generic substance misuse and mentalhealth) services effectively if the workers in these services had additional training around dual diagnosisissues

• People whose mental health needs are best met within mental health agencies, but whose substancemisuse is such that they also require the help of a specialist substance misuse counsellor

• People with serious and multiple needs, whose lifestyles have become chaotic and self-destructive, andwho require sustained and intensive specialist support from people who are specialists in dual diagnosis

(See article: ‘Perspectives on Multiple Needs CASA MNS 1998’)

Raising expectations

Training can also help to address negative attitudes to clients and low expectations for outcomes. It is also important to address low expectations with clients themselves.

Good practice examplesThe following provide practical examples of how dual diagnosis issues are being addressed at a local level.

Barnet Dual Diagnosis Steering Group

This group has recently been set up by Turning Point’s dual diagnosis lead at a community drug andalcohol project in Barnet called ‘The Crossing’.

Its main purpose is to consolidate and improve referral pathways and systems of support for clients with co-existing substance misuse and mental health problems.

The group brings together primary leads of services working with dual diagnosis from voluntary andstatutory agencies. It currently includes a lead consultant psychiatrist from Barnet, Haringey and Enfield Mental Health Trust, two social work department managers, the clinical drug and alcohol servicemanager, the Dual Diagnosis coordinator and clinical psychologist, the senior team leader of thecommunity drug and alcohol service, the A&E psychiatric liaison nurse and will include a service user.

A number of problems in meeting client need were identified:

• Difficulty of agreeing a local definition of “dual diagnosis”• Different views from psychiatry and substance misuse services on who should be responsible

for a given person’s package of care• Confidentiality – there were no existing protocols about information sharing or referrals• Time to attend meetings– many professionals had conflicting priorities

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Many of the solutions were focused around better dialogue between a wide range of healthcaremanagers and practitioners. Each party became clearer about their own role and that of other agencies.As a result, referral and through care pathways became clearer, more consistent and more appropriate for the individual. There is also a locally agreed definition of dual diagnosis.

Another valuable improvement has been the extent to which service users and their representatives have been able to influence policy and practice. An example of this is described below.

Improving liaison between A&E and community services

A statutory psychiatric liaison team provides all-day and evening cover five days a week in the accident and emergency (A&E) department in Barnet hospital. The team consists of a co-ordinator and two nurses. The coordinator attends the dual diagnosis steering group in Barnet and is part of the community mental health team. Consequently the co-ordinator is well placed to refer and liaise with all mental health services.

The psychiatric liaison workers also have excellent links with other community and clinical services,including substance misuse. When making a referral to substance misuse services, the psychiatric liaison workers use standardised letters and include a copy of the assessment carried out in A&E. This details fully the reason or incident that brought the person to A&E and provides contact details of other professionals or agencies involved in the person’s care. This is useful in pursuing letters or reports that may be relevant to compiling a risk assessment and also helps to foster joint working.

A copy of the Care Plan is also attached to the referral. This will include a plan to attend The Crossing, or another agency, for support regarding their substance use. A letter is then sent out from the substance misuse service, inviting the client to attend their service for a more comprehensiveassessment or a specific type of support that is offered.

Patients from A&E are regularly referred to The Crossing’s drop-in service and Barnet Drug and AlcoholService (the clinical substance misuse service), where an initial/triage assessment is carried out. Everyweek during one of these drop-ins, a dual diagnosis co-ordinator, employed by Barnet Drug and AlcoholService, attends the drop-in to provide support with the high volume of ‘dual diagnosis’ clients.

This is a good example of effective joint working between substance misuse services and betweenstatutory and voluntary agencies.

The psychiatric liaison co-ordinator has invited substance misuse services to provide training tocommunity mental health team staff. This has included community psychiatric nurses, mental healthsocial workers, A&E and other hospital staff. The training covers both issues relating to drugs and/or alcohol and the services available. Reciprocal training has also been arranged.

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Turning Point: Druglink Hammersmith and Fulham Complex Needs Service

Druglink Hammersmith and Fulham is a street agency providing a wide-range of project-based andoutreach services to people affected by their own problematic drug use. It also offers advice and support to families, friends and other professionals. The Complex Needs Service was developed in 2002 to meetthe needs of a growing number of clients with severe and enduring mental health problems, complicatedby substance misuse and often further compounded by physical and/or learning disabilities.

This client group had high and multiple levels of need, but were ‘falling through the gaps’ between mental healthand substance misuse services whilst staff lacked the confidence and training to provide adequate help.

The service provides individual sessions based on psycho education and cognitive behavioural therapy, alongside a series of life skill workshops and complementary therapies. To ensure accessibilityand maximise engagement, it is flexible in terms of times and locations. It provides satellite services atsupported accommodation projects as well as in-reach into in-patient psychiatric wards and home visits.The service is currently led by one specialist Complex Needs Worker. This person shares expertise locally by offering training, support and consultancy to a wide range of professionals from both specialistand generic services.

Resulting improvements include better communication and relationships between agencies in theborough, clearer pathways and continuity of care, and greater support for clients and workers. It is alsodemonstrating successful collaborative working with a diverse range of services in difficult situations. For example providing a multi-agency in-reach service to long-term in-patients to enable a seamlesstransition from hospital into the community.

A whole person approach to a range of needs

Mark is typical of the clients coming to Turning Point’s Housing Link service in Hemel Hempstead. He had clinical depression and had just completed his third residential alcohol detox. He was in animpossible situation, trying to stay alcohol free whilst living in a shared house with people who were still using drugs and alcohol. Rent arrears were intensifying his problems. Although registered with the council housing department for alternative accommodation, he was considered a ‘low priority’.

Carol, a Support Worker, worked with Mark over 18 months to address a number of issues. Partnershipworking is considered vital to empower clients and equip them with the skills they need for the future. The first task was for Mark to claim Disability Living Allowance and other benefits to which he wasentitled. Through applying for back dated Housing Benefit, Carol was able to support Mark to clear hisrent arrears, this enabled him to move more quickly. She also liaised with the Council and HousingAssociation providing his current housing to eventually secure his own flat.

Mark had not been in contact with a GP or the Community Mental Health Team for several years. So, to address his anxieties about explaining his needs and engaging with other services, Carolaccompanied him to initial appointments if requested. He realised that living on his own would bringdifferent challenges and Carol helped him to find out about local drop in services as well as pottery and art classes. She also encouraged him to renew contact with his family.

Carol continued to visit regularly for several months and Mark was able to access the service again to help him through a difficult period some months later.

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Action points for practitioners• Use the networking tool provided with this toolkit to identify the range of relevant services in your area• Check that you have up to date contact details for these together with descriptions of the service

provided and details of their referral criteria and procedures• Agree a local definition of dual diagnosis• Look at the protocols that exist for inter-agency working and do a reality check. Do the protocols

describe what actually happens or are there gaps in practice?• Involve service users and carers in mapping people’s actual experiences of services against the

theoretical models. Use this to identify actions and develop a clear plan for ongoing care that is sharedwith all services

• Where there are gaps/problems alert your managers and/or arrange a multi-agency meeting to discussthe issues so that each party understands their role and that of other agencies

• Do a training needs audit within your team and act upon identified needs. Consider reciprocal trainingbetween mental health and substance misuse services

References and resources

In this section we provide:

• References for the preceding chapters• A description of the most commonly used substances• A fuller description of the policy context for dual diagnosis• Suggestions for further reading• Useful addresses

References Section one: Introduction

1 Dual Diagnosis Information Manual - Co-existing problems of Mental Disorder and Substance Misuse,The Royal College of Psychiatrists (2002)

2 J. Marsden et al. Psychiatric symptoms among clients seeking treatment for drug dependence. Intakefrom the National Treatment Outcome Research Study, 176 Br, J. Psychiatry 285-289 (2000)

3 Quoted in Dual Diagnosis Good Practice Guide (2002), Department of Health

Section three: Substance Use

References used throughout this section:

The Druglink Guide to Drugs (2004), Drugscope (Available from Amazon.co.uk. ISBN 1-904319-16-5 Price: £8.50)

Co-existing Problems of Mental Disorder and Substance Misuse (Dual Diagnosis) - an Information Manual(2002). The Royal College of Psychiatrists (www.rcpsych.ac.uk/cru/complete/ddipPracManual.pdf)

British Crime Survey information available at: www.homeoffice.gov.uk/rds/bcs1.html

Patterns of Substance Misuse

National Alcohol Harm Reduction Strategy (2004), Department of Health

Section four: Mental health problems

Bateman, A. and Tyrer, P. (2002) Effective management of personality disorder, Department of Health

Personality disorder

No longer a diagnosis of exclusion. Policy implementation guidance for the development of services forpeople with personality disorder, National Institute for Mental Health in England (NIMHE) (2003)(www.dh.gov.uk/mentalhealth/personalitydisorder.pdf)

The Personality Disorder Capabilities Framework NIMHE (2003)(www.nimhe.org.uk/downloads/personalitydisorders.pdf)

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Psychological interventions

A useful resource is ‘Recent Advances in understanding mental illness and psychotic experience’. (Available at the British Psychological website www.bps.org.uk)

Involving users, families and carers

There may be a local user group or organisation in your area that can provide advice.

National information includes:

• The Joseph Rowntree Foundation findings: ‘Increasing user involvement in voluntary organisations’ July (2003). Ref 723 www.jrf.org.uk

• A Fair Day’s Pay: A guide to benefits, service user involvement and payments. Mental Health Foundation,July (2003). Price: £8 (free to unwaged)

The Sainsbury Centre for Mental Health has also begun a pilot entitled Service User Empowerment andLeadership Programme.

Making services more culturally appropriate

BME communities

1 http://image.guardian.co.uk/sys-files/Society/documents/2004/02/12/Bennett.pdf

Wanigaratne S, Unnithan S and Strang J Substance misuse and ethnic minorities: issues for the UK(published in Psychiatry in Multicultural Britain: (2001) p. 243-263)

For further information on the Department of Health’s Strategy: Delivering Race Equality: a Framework forAction and other key documents see www.nimhe.org.uk/priorities/black.asp

Women

Brunette, MF and Drake, RE (1997) Gender differences in patients with schizophrenia and substancemisuse. Compr Psychiatry Mar-Apr 38(2):109-16

Crome I (1997) Gender differences in substance misuse and psychiatric comodidity. Current Opinion inPsychiatry 1997, 10: 194-198

For further information on the Department of Health’s Women’s Mental Health Strategy MainstreamingGender and Women’s Mental Health and other key documents see www.nimhe.org.uk/priorities/women.asp

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Lesbian, gay, bisexual and transgender

Lesbian

1 Mental Health and Social Wellbeing of Gay Men, Lesbians, and Bisexuals in England and Wales –Principal Authors: Professor Michael King and Dr Eamonn McKeown, Mind (2003) (www.mind.org.uk)

2 Richard Dyter and Philip Lockley Drug Misuse Amongst People from the Lesbian, Gay and BisexualCommunity: A Scoping Study, Home Office (2003) (www.drugs.gov.uk)

Further resources for LGBT issues include:

DeAngelis, T., New Data on lesbian, gay and bisexual mental health. Monitor on Psychology Vol 33 (2002)

PACE, a Lesbian, Gay and Bisexual Mental Health Organisation Tel: 020 7697 0014 www.pacehealth.org.uk pace@dircon.co.uk

Antidote, Specialist LGBT Substance Misuse Service Tel: 020 7437 3523 antidote@turning-point.co.uk

Queery – searchable LGBT community database for other referrals www.queery.org.uk

Section six - Structures

Rankin J & Regan S (2004) Meeting Complex Needs: The Future of Social Care, Turning Point/IPPR Price: £9.95

1 Keys to Engagement, Sainsbury Centre (1998)

2 Checinksi K: Treatment Strategies and Interventions. Chapter 10 in Dual Diagnosis: Substance Misuseand Psychiatric Disorders G. Hussein Rassool, Blackwell Science (2002).

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Section five: In Practice

Assessment1 Co-morbidity of substance misuse and mental disorders available from

www.nelmh.org/content_show.asp?c=17&fid=663&fc=008001

2 Moore K & Rassool GH: A Synthesis of Addiction & Mental Health Nursing: An Approach to Community Interventions. Chapter 8 in Dual Diagnosis: Substance Misuseand Psychiatric Disorders, Blackwell Science (2002)

The Diagnostic and Statistical Manual Four.(Available from Amazon Price: £55.95)

Managing risk

Assessment and Management of Risk of Harm in Clients with Dual Diagnosis.(Published by Alcohol Concern in association with Drugscope, March 2002. Price: £10)

Types of treatment provided by substance misuse services

Much of the information in this section comes from Treatment Works, an initiative involving the majorvoluntary substance misuse agencies in the UK. More information and resources are available fromwww.treatmentworks.co.uk

Treatment via the criminal justice system

This information is adapted from the Home Office website. More details are available from:www.drugs.gov.uk/NationalStrategy/CriminalJusticeInterventionsProgramme

Stages in treatment

Osher, FC and Kofoed, LL, (1989) Treatment of patients with psychiatric and psychoactive substance abusedisorders. Hospital and Community Psychiatry 4 (10), 1025-30

Active treatment

Co-existing Problems of Mental Disorder and Substance Misuse (Dual Diagnosis) - an Information Manual(2002). The Royal College of Psychiatrists. (www.rcpsych.ac.uk/cru/complete/ddipPracManual.pdf)

Factors involved in relapse prevention

Also see above

Miller WR & Rollnick S (1991) Motivational Interviewing: preparing people to change addictive behaviour.New York, Guildford Press

Prochaska J & DiClemente C (1986) Towards a comprehensive model of change. In W Miller and N Heather(Eds) Treating addictive behaviours: Processes of change. New York, Plenum Press

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Appendix 1

The most commonly used substances and their effectsIt is important to remember that the effects of any substance will vary from one individual to another. This will depend on the quality and quantity of the substance and the person’s age, gender, weight, mood,culture, expectations and state of physical and mental health. Street drugs are almost always cut (mixed)with other substances to bulk out the drug and maximise profit. As a result, the appearance and potencyof drugs varies widely. Unless a sample of a drug is tested it is not possible to know exactly what it is.

With many drugs, regular users may develop tolerance. They may then require more of the substance toachieve the same effect. Users may alter their method of use to increase potency – for example fromsnorting to injecting. Users appear not to become notably physically dependent, but may become verystrongly psychologically dependent.

Injecting involves additional health risks such as blood borne viruses including HIV and Hepatitis B and C;infection from sharing needles; septicaemia and damage to the heart valves. Some effects may prove fatal,especially if combined with other substances.

The following information covers the principal legal and illegal substances under these headings:

• Description • Legal status/class• Method of use• Signs: description of common symptoms. (Note: these will vary and not all will be experienced)• Sought after effects• Adverse effects

Stimulants (uppers)Some stimulants are very strong – for example cocaine and amphetamines. Others like caffeine andnicotine are relatively weak. However it is smoking that causes the most severe long-term health problems.

Overall effects of stimulants

Stimulants force the release of the body’s own energy chemicals and stimulate the reward/pleasure centre.They also constrict blood vessels, speed the heart and raise blood pressure. Prolonged use of the strongerstimulants depletes energy resources, and triggers intense craving.

Stimulants can also cause or mimic mania, anxiety and/or depression or paranoid psychosis. Users appear not to become physically dependent, but may become psychologically dependent. Cocaine andamphetamine withdrawals can resemble a major depression. The direct effects of the stronger stimulants,combined with the exhaustion of withdrawal can cause or mimic a bipolar illness that includes manicdelusions and then depression. Cocaine causes the most rapid stimulation and subsequent comedown of all the stimulants.

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Amphetamines - speed, whizz, sulph, uppersA white powder or tablets.Use: swallowed, sniffed, smoked or injected (by crushing the tablets).Legal status: Prescription only medicine, Controlled drugs. Class B.Signs: increased alertness and dry mouth, excessive fluid intake.Sought after effects: elevation of mood, boost of confidence, energy levels or wakefulness, suppression of appetite.Adverse effects: initial pleasurable rush followed by anxious feelings, exhaustion (leading to excessive sleep) and depression, irritability, and paranoia. Heavy users may experience severe weight loss and psychosis, hallucinations and delusions and may become aggressive.

Anabolic steroids - eg nadralone, dianabol, durabolin, primobolin, stanozolol, winstrolThese are synthetic drugs similar to natural hormones. They promote protein build up and therefore muscle gain.Use: swallowed as tablets or injected. They should be taken in cycles of a number of weeks of using/not using but multiple mixtures and on-going use is common. Widely available in gyms.Legal status: Prescription only medicines. Class C.Signs: muscle growth and deepening of the voice.Sought-after effects: to build up muscle size and body strength.Adverse effects: Can be associated with mental health problems (eg mania and depression). They affect mood and can cause aggression and paranoia. Use is prevalent amongst young men who may have emotional problems and are drinking heavily. There is a high level of injecting, but users do not perceive themselves as drug users and do not engage with substance misuse services for clean equipment bringing associated dangers of injecting. There is also a recent trend in injecting insulin. There is an increasing supply of counterfeit products which do not attract the same controls for quality or dose as for licit steroids.

Cocaine - charlie, coke, snow, foot, lady, CA white powder, usually 'cut' or mixed with other fillers.Use: sniffed, injected, smoked or eaten.Legal status: Class A.

Crack cocaine - rocks, ready wash, ice, baseIrregular lumps, looking like sugar, whitish in colour.Use: crushed then heated and the fumes inhaled.Legal status: Class A.Signs: same as above, but effects can be more pronounced.Sought after effects of cocaine and crack cocaine: a rapid intense high, Makes the user more confident and talkative. The high is only short lived leaving the user craving more. Can stimulate the sex drive.Adverse effects: anxiety and exhaustion, long periods of sleep, irritability, depression and paranoia. Sudden rise in blood pressure and slowing of heartrate. Overdose can cause sudden heart attack or strokes after prolonged

use. Highly addictive. As tolerance grows, the margin narrows between a dose producing euphoria and one that is fatal. Heavy users may experience psychosis, hallucinations and delusions and may become aggressive.

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Many cocaine and crack users also take other drugs, including heroin. In some parts of the country, usersare engaging in the highly dangerous practice of injecting a mixture of heroin and cocaine (known assnowballing or speedballing). Alcohol is often involved too. When alcohol is mixed with cocaine, a thirdsubstance – cocaethylene - is formed. This substance lasts longer in the body, is more toxic, and causesmore harm, especially to the cardio-vascular system. (Taken from Know the Score: Crack and CrackCocaine, produced by the Scottish Executive see www.knowthescore.info)

Khat – (also spelled Quat, Qat and Kat)Leaves from the Catha Edulis plant - most powerful when fresh.Use: users usually chew leaves or shoots for several hours and swallow the juice.Legal status: the Khat plant is legal, but its active ingredients cathinoneand cathine are Class C.Signs: irritability, increase in spitting, talkativeness.Sought after-effects: Mild euphoria, hallucinations.Adverse effects: dependence can develop and heavy use can be problematic.Increased aggression, hallucinations, nausea, vomiting. Continued use can lead to cycles of sleeplessness and irritability and can in the longer-term lead topsychiatric problems such as paranoia and possibly psychosis.

Khat acts as a social lubricant in mostly Muslim countries, with links to (especially) the Yemen, Ethiopia or Somalia. Effects start after approximately 30 minutes with stimulation and talkativeness. This is followed by a relaxed and introspective state that can last up to 5 hours, often with an inability to sleep. This is then followed by periods of lethargy, irritability and general hangover.

Khat is also often used with tobacco. This brings additional associated risks such as respiratory problems. Mouth ulcers and problems in the digestive tract are also common among users.

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Sedative-Hypnotics (Anti-anxiety drugs)Sometimes called anxiolotics or minor tranquillisers, these drugs are used medically (on prescription) andare also abused for their effects. When used to treat anxiety, they are called minor tranquillisers/sedativesand when used to treat sleeping problems, they are known as “hypnotics” or sleeping tablets.

Benzodiazepines are the most frequently prescribed sedative-hypnotics. They were developed as saferalternatives to barbiturates but tolerance, addiction, withdrawal and overdose still occur. There are alsoother problems with the millions of depressant drugs prescribed by doctors including polydrug use, crosstolerance and cross dependency. Dependency on benzodiazepines is extremely dangerous. Stopping useabruptly if dependent (usually 3 weeks or more) should be avoided and medical advice sought.

Tranquillisers – temazepam – (te)mazzies, eggs, jellies, mogadon – moggiesPills, tablets, capsules in a variety of shapes and colours.Use: swallowed or injected.Legal status: Prescription only medicine. Controlled drugs. Illegal to possess without a prescription.Benzodiazepines and minor tranquillisers (Class C).Signs: see adverse effects.Sought after-effects: increased relaxation and calmness.Adverse effects: higher doses cause drowsiness, reduced co-ordination and concentration, anxiety and epilepsy.

Depressants (downers)Overall effects of depressants

Overall, downers, particularly where there is excessive use, can cause or mimic a depressed mood. Theymay cause loss of motivation and interest in surroundings, other people or oneself leading to self-neglectand even self-harm, including attempted suicide. Effects are particularly dangerous if combined with otherdrugs. Excessive sleep may be one of the characteristics of a major depression.

It is easy to overdose on downers, particularly where there is alcohol use. Where there has been regular orheavy use of downers, it is important that the person does not suddenly stop. Rapid withdrawal (especiallycombined with a withdrawal from alcohol) can cause serious problems including tremors, sweating,cramps, transitory hallucinations, stomach pains and even seizures or deliriums tremens called DTs.

Alcohol – booze, bevy, popUse: is taken orally. Alcohol is absorbed in the bloodstream and its effectsdepend on its strength and the individual. Food will delay absorption. Use is common among people with mental health problems.Legal status: Can be bought by adults 18+ (or drunk outside a pub by children 5+) Need a license to sell.Signs: include slow or slurred speech, poor co-ordination (see adverse effects below).Sought after effects: if a person is not at risk (e.g pregnant, in recovery, or with mental or physical health problems) there are some benefits. In general, sedation, muscle relaxation and lowered inhibitions and increasedconfidence accompany low to moderate use.

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Adverse effects: with high doses, a range of effects occur from decreased alertness and exaggeratedemotions to shock, coma and death. Effects are directly related to the amounts, frequency and duration of use and also depend on the tolerance of the user. Depending on a drinker’s habits and susceptibility, organ damage, particularly liver damage, nutrition deficits and sexual problems can occur. Alcohol affectsco-ordination and reactions, so users are prone to accidents. It is also the leading cause of birth defects in those cases where a cause can be attributed.

The effects of withdrawal from alcohol can be severe and requiring medical supervision for detoxification.These include hallucinations, seizures and DTs and in some cases death.

Chronic drinking As defined by the Department of Health, chronic drinkers are those who drink large amounts regularly.(Around a quarter of the population drink above the former weekly guidelines of 14 units for women and 21 units for men). Excessive, chronic drinking causes tolerance and tissue dependence. Withdrawalsymptoms can occur upon cessation of drinking. Altered body chemistry can lead to dependence.

Binge-drinkingThis is taken to mean drinking to get drunk or drinking substantially above recommended daily guidelinesin one session.

Cannabis - dope, draw, blow, resin, grass, skunkLike tobacco or a dark brown resinCannabis can have hallucinatory effects and stimulant properties, but is regarded mainly as a depressant or relaxant.Use: smoked, eaten or drunk as an infusion.Legal status: controlled drug Class C.Signs: blood-shot eyes, hunger pangs.Sought after effects: some users experience an intense feeling of relaxation. If eaten, effects last longer than when smoked.Adverse effects: can include lethargy, demotivation, panic, paranoia and short term memory loss. Heavy use, particularly if strong varieties such assome forms of skunk are used regularly, can lead to psychosis. There are also health risks associated with smoking.

GHB – GBH, Liquid E, Liquid XA colourless liquid, with a slightly salty taste. Sometimes sold as ‘liquid ecstasy’, but is not related to ecstasy.Use: by body-builders and on the club scene.Legal status: controlled drug – Class CSigns: similar to alcohol, with the user appearing drowsy or drunk.Sought-after effects: slows body actions, euphoria.Adverse effects: as dosage increases, euphoria is replaced by powerfulsedative effects, with reports of nausea, vomiting, muscle stiffness, confusionand sometimes at high doses, convulsions, coma and respiratory collapse.

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HallucinogensThe most commonly used hallucinogens are LSD, MDMA (“ecstasy”), PCP, mescaline and psilocybinmushrooms (magic mushrooms).

Overall effects of hallucinogens

Hallucinogens cause intensified sensations, mixed-up sensations (visual input becomes sound), illusions,delusions, hallucinations, stimulation and impaired judgement and reasoning. LSD is very potent and cancause delusions. On some occasions, users can experience a “bad trip”, which can be very frighteningboth for the user and any onlooker. Flashback may occur for a considerable length of time after the original“trip”. Magic mushrooms cause nausea and create hallucinations. Mescaline used in sacred rituals andceremonies cause more hallucinations than LSD, and designer hallucinogens like ecstasy are similar toamphetamines but also have calming and psychic effects. PCP, an animal tranquilliser, causes mind-bodydissociation and a sensory deprived state. Ketamine (“Special K”), a powerful anaesthetic, is becomingmore popular and has a potential for causing hallucinations and other ‘psychotic’ outcomes.

Hallucinogens generally are unpredictable and can trigger a latent mental illness. They can also cause or mimic delusional hallucinations and paranoia associated with a major psychosis.

Ecstasy (or MDMA) - E, adam, XTC, dovesTablets, powder and capsules in many shapes and colours. Use: usually swallowed, sometimes can be injected and occasionally snorted.Legal status: Class A.Signs: increased energy, slurred speech.Sought after effects: 20-60 minutes after use, user experiences euphoria which plateaus for 2-3 hours before wearing off. Feelings of empathy,meaningfulness and relaxation.Adverse effects: tiredness, confusion, anxiety, depression and paranoia. Suddendeath through overheating and dehydration or drinking too much water. A minorityexperience liver damage and strokes. Some users report panic attacks, paranoidpsychosis and depression. Dependence is possible if taken frequently.

LSD - acid, tabs, tripsSmall tablets or printed squares of paper impregnated with the drug. Also comes in liquid form.Use: swallowed or sucked, can be absorbed through bodily membranes such as the eyes or anus.Legal status: Class A.Signs: being detached from reality, giggly, unable to communicate coherently, slurred speech, lack of co-ordination.Sought-after effects: to induce an altered state of consciousness. LSD distorts shapes, colours and sense of time, producing hallucinations, laughter or exhilaration.Adverse effects: can include flashbacks, anxiety and paranoia. Can precipitaterelapse in those already susceptible to schizophrenia. Users often underestimate

the length of a trip and feel exhausted physically and psychologically after a 12-36 hour experience. A lack of control and ability to stop the experience can frighten users.

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Mushrooms - shrooms, silly simons, mushiesMushrooms, a variety of wild growing fungi, native to the UK, such as the Liberty Cap. International varieties are becoming more widely available through specialist shops and the internet. The key constituent is psilocybin. Use: eaten raw, cooked or drunk as an infusion.Legal status: if prepared for use may be a controlled drug.Signs: being detached from reality, giggly, unable to communicate coherently, slurred speech, lack of co-ordination, vomiting.Sought after effects: similar to LSD, but the trip is often milder and shorter. Adverse effects: can include stomach pains, sickness and diarrhoea.Misidentification can lead to users eating poisonous varieties which can prove fatal.

Opiates and opioidsOpiates and opioids are natural, semi-synthetic, and synthetic derivatives of the opium poppy. Theprincipal opiates and opioids are heroin, codeine and morphine. Others include methadone and otheranalgesics (painkillers), which are widely used.

Heroin - junk, smack, skag, H, gear, brownSold illicitly as a powder, usually brown, but can be white.Use: can be injected, swallowed or smoked – after heating it over a flame and then inhaling through a tube such as an empty pen. The most common street use is mixing it with water and injecting it. Diverted pharmaceutical tablets may be swallowed or crushed and injected.Legal status: prescription only medicine. Class A.Signs: slow shallow breathing, drowsiness and constricted (small) pupils,watering eyes & nose, itching, fidgeting.Sought after effects: provide powerful relief from physical pain (for which they are used medically) and also of psychological pain. It induces euphoria,which may wear off but use continues to avoid withdrawal symptoms.Adverse effects: running nose and eyes, irritability, tremors, chills. Sudden withdrawal leads to cramps, sweating and diarrhoea and “goose bumps.”Dependence develops after repeated use over several weeks. Not all users are dependent, but heroin is difficult to manage recreationally. Tolerance develops quickly.

Methadone - doll, red rock, juice, ‘script’Usually in the form of white tablets or liquid.Use: swallowed or sometimes in injectable form.Legal status: prescription only medicine. Class A.Signs: slow shallow breathing, drowsiness and constricted (small) pupils,watering eyes & nose, itching, fidgeting.Sought after effects: the effects are similar to heroin, however methadonetincture cannot be injected which helps to reduce the associated risks of this practice. Provide powerful relief from physical pain (for which they are used medically) and also of psychological pain. It induces euphoria, which may wear off but use continues to avoid withdrawal symptoms.Adverse effects: Some people are sick the first time they take drugs like Methadone. For women, use can cause irregular periods (although conception is still possible). It can cause constipation.

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Methadone is usually prescribed as a substitute for heroin either to stabilise or reduce use. It is alsoregarded as equally and sometimes more addictive than heroin. Sold illicitly either through selling onprescriptions or diverted from legal sources, it may be used when heroin is difficult to obtain. Many opiateusers who are prescribed methadone may often seek street heroin to top up their dose either because theprescription is not high enough or the effects are not strong enough. Dose management, appropriate toeach individual, is therefore extremely important.

Other substitute drugs for opiate dependency may also be used such as Subutex, with less of a buzz orsense of euphoria that methadone provides. Naltrexone is an antagonist, it prevents the neuro-receptors in the brain from picking up the effects of opiate drugs.

Volatile SubstancesMore than 100 commercially available products are now used to get high. They include: lighter fuel, glues,rubber cement, tippex™ fluid, nail polish remover, magic markers, petrol, paint and paint thinners, cleaningfluids, aerosols, fire extinguishers - the list is endless.

Overall effects of volatile substances

The inhaled vapours are absorbed through the lungs and pass rapidly through the blood to the brain. Theyact on the central nervous system, sometimes as a stimulant but generally as a depressant, putting a clampon that part of the brain (the cortex) which is believed to “check” primitive instincts. “Disinhibition” results.

General body functions like breathing and heart rate are depressed and there is a “stoned” feeling lastingfrom a few minutes to half an hour. Headaches, sickness and dizziness are not uncommon, particularly for novices. Continued or deep inhalation causes disorientation, drowsiness, numbness and perhapsunconsciousness - much like the effects of medical anaesthetics. The experience is said to be like that of being drunk and can produce euphoria, aggression, deep melancholy, giggling and raised libido.

Alkyl nitrites (amyl, butyl and isobutyl)- “Poppers”, rush, locker room, hard coreClear yellow liquids.Use: fumes from the liquid are inhaled. Effects are short lived. Popular on the dance scene and in clubs.Legal status: Pharmacy medicine.Signs slurred speech, poor co-ordination.Sought-after effects: an initial rush followed by light-headed feelings. Used to facilitate sex (often among the gay community).Adverse effects: fainting, loss of balance, headaches and nausea. Swallowing the liquid can be fatal but is rare.

Solvents - (brand names)Off the shelf products.Use: sniffed or inhaled. Signs: watering eyes and nose, poor co-ordination, slurred speech.Sought-after effects: “to get high”Adverse effects: use is most common among early teens (12-15) and is often short term, but can be very dangerous. Continued use can lead tonumbness or unconsciousness, propellant gasses can freeze the vocal cordscausing asphyxiation. Associated dangers include accidents, choking on vomit or heart failure. Long-term use can impair visual and bladder function.

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Appendix 2

The policy context for dual diagnosisThere has been increasing recognition of the extent of co-existing mental health and substance misuseproblems in recent years. This is reflected both in legislation and frameworks affecting service delivery.Whilst acknowledging that co-existing disorders occur on a spectrum, it should be noted that the focus of many policies is on people with more severe problems who have been given a formal diagnosis of dual diagnosis.

This section summarises the main initiatives, but is not intended to be a critique of policy.

The Mental Health National Service Framework 1999

The ten year National Service Framework for Mental Health (NSFMH) published in September 1999 sets out how services will be planned, delivered and monitored. It is relevant to all providers, the NHS,social services and voluntary and independent agencies. Seven standards set targets for the mentalhealth care of adults up to age 65. These span 5 areas – health promotion and stigma, primary care and access to specialist services, the needs of those with severe and enduring mental illness, carers’needs and suicide reduction.

In relation to dual diagnosis, the Framework emphasises the following:

Under mental health promotion:• Development of specific programmes to combat discrimination and social exclusion of vulnerable

groups, including individuals with mental health and alcohol and drug problems• Brief primary care interventions such as assessments of alcohol intake, which can reduce excess

consumption• Stronger links between drug and alcohol services and community mental health services to help

reduce suicide

Under primary care:• Assessments of individuals with mental health problems should consider the potential role of

substance misuse

Under specialist services:• The needs of people with dual diagnosis through existing mental health and drug and alcohol services.• People with severe mental illness who have high rates of psychological or physical morbidity should

receive appropriate and responsive care. Services should ensure that crises are anticipated or prevented wherever possible

• The Care Programme Approach (CPA) is a framework for inter-agency working set out by theDepartment of Health. It should be applied to people with dual diagnosis whether they are located in mental health or drug and alcohol services. The programme must start with a proper assessment(see page 30)

• Assertive outreach and crisis resolution services are seen as the main focus for work with people who have dual diagnosis. These must be adequately resourced and trained. Training for all staff,particularly in substance misuse and long-term engagement with clients, is identified as important

See www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4009598&chk=jmAMLk

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Models of Care

This sets out a national framework for the commissioning of an integrated drug treatment system foradult drug misusers in England. Published by the National Treatment Agency (NTA) in partnership withthe Department of Health, Models of Care has similar status to a national service framework. Its aim is to support Drug Action Teams (DATs), joint commissioners and providers to develop an efficient andeffective treatment and care system for all drug misusers. It groups services into four tiers (see page 36).

Models of care places considerable emphasis on care co-ordination and on meeting the multiple needs of a person misusing drugs or alcohol through an integrated care pathway. This involves linksbetween substance misuse treatment provision and other generic health, social care and criminal justiceservices. Care plans are designed to ensure that a client’s care is co-ordinated, comprehensive and hascontinuity. All commissioners of drug treatment services are expected to plan and commission servicesbased on the system outlined in Models of Care.

See www.nta.nhs.uk

Dual Diagnosis Good Practice Guide

Published by the Department of Health in May 2002, this is the most relevant document concerning dual diagnosis. It summarises current policy and good practice in the provision of mental health services to people with severe mental health problems and problematic substance misuse.

This toolkit makes frequent reference to the guide but the key points are summarised below:

The primary responsibility for the treatment of individuals with severe mental illness and problematicsubstance misuse should lie within mental health services. This approach is known as ‘mainstreaming’and aims to lessen the likelihood of people being shunted between services or losing contact completely.

In addition, substance misuse agencies (both alcohol and drugs) should provide specialist support,consultancy and training to mental health teams.

Mental health services should offer similar support to substance misuse agencies to enable them toeffectively treat those with less severe mental health problems.

Clear pathways of joint working and treatment should be developed in dual diagnosis strategic planning.

Local Implementation Teams (from mental health) and Drug Action Teams (from substance misuse) are responsible for the implementation of the Guide’s requirements.

See www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4009058&chk=sCQrQr

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The Mental Health Act 1983

This Act sets out the circumstances in which an individual can be detained in hospital for assessmentand/or treatment for their mental disorder without their consent. A person cannot be detained by reasononly of dependence on alcohol or drugs. They must also have a mental health disorder at a level atwhich they are considered to present a danger to themselves or others. Some people with co-existingconditions are being excluded from compulsory treatment. The draft Mental Health Bill proposes that the so-called exclusion clauses are dropped from legislation.

See www.markwalton.net/guidemha/index.asp?

The National Alcohol Harm Reduction Strategy for England

Published in March 2004, this document sets out the Government’s strategy for tackling the harms andcosts of alcohol misuse in England. The strategy states that binge drinkers and chronic drinkers are atparticular risk of harm. It identifies particularly vulnerable groups such as ex-prisoners, street drinkers,young drinkers and those who are likely to experience other problems such as mental illness and druguse, which may compound multiple needs. It does not recommend specific actions for such groups.However, it is envisaged that measures to help them will be encompassed in the four main ways totackle alcohol related harm. These are: improved education and communication; better identification and treatment of alcohol problems; tackling crime and anti-social behaviour; and closer working with the drinks industry.

The strategy recognises that treatment for a person’s alcohol problems may fail due to lack of co-ordination and links with other services. It therefore contains a commitment to work with the National Treatment Agency to develop guidance within the Models of Care framework on integrated care pathways for vulnerable groups.

See www.strategy.gov.uk/su/alcohol/index.htm

Updated Drug Strategy

This was published by the Drug Strategy Directorate at the Home Office in 2002.

The Government’s drugs strategy has the overarching aim of reducing the harm that drugs cause tosociety, including communities, individuals and their families. Key targets include: reduction of the use of Class A drugs and the frequent use of illegal drugs by young people; and the increase of problemdrug users in treatment. It places particular emphasis and funding on expanding interventions within the criminal justice system.

The Strategy acknowledges that those with complex needs find it difficult to access the help they need.However, it does not explicitly mention any specific measures to improve provision for poly-drug users or those with co-existing mental health needs.

See www.homeoffice.gov.uk/drugs/strategy/index.html

The Legal FrameworkThere are two main statutes regulating the availability of drugs in the UK: the Misuse of Drugs Act, and the Medicines Act.

The Misuse of Drugs Act 1971 This is intended to prevent the non-medical use of certain drugs. For this reason it controls not justmedicinal drugs (which will also be in the Medicines Act) but also drugs with no currently recognisedmedicinal uses. Drugs subject to this Act are known as “controlled” drugs. The law defines a series ofoffences, including unlawful supply, intent to supply, import or export (all these are collectively known as “trafficking” offences), and unlawful production. The main difference from the Medicines Act is that the Misuse of Drugs Act also prohibits unlawful possession. To enforce this law the police have thespecial powers to stop, detain and search people on “reasonable suspicion” that they are in possession of a controlled drug.

The Act divides drugs into three classes:

Class A: These include cocaine and crack (a form of cocaine), ecstasy, heroin, LSD, methadone,processed magic mushrooms and any Class B drug which is injected. Class B: These include amphetamines, barbiturates, and codeine. Class C: These include benzodiazepines, anabolic steroids, GHB and minor tranquillisers. Cannabis (in herbal or resin form) was reclassified to Class C in January 2004.This means thatpossession carries a reduced maximum sentence. The police have been issued with guidance advisingthem not to arrest for simple possession unless there are aggravating factors such as when the drug is being smoked in areas which minors frequent eg schools and youth clubs. However, the police willretain the power to arrest if they think it is appropriate, regardless of aggravating factors.

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Use/production of drugs on work premises

Section 8 of the Misuse of Drugs Act

The current law makes it a criminal offence for people to knowingly allow premises they own, manage, or have responsibility for, to be used by any other person for:• production or attempted production of any controlled drug • supply or attempted supply of any controlled drug • preparation of opium for smoking• smoking of cannabis, cannabis resin or prepared opium

Professionals can be prosecuted if they knowingly allow any of these things to occur on work premises,which they ‘occupy’. The same legal obligations could apply to people with regard to their own homes.The law requires that if staff become aware of the use or supply of illicit drugs on their premises, they must take reasonable action to prevent this continuing.

An amendment to Section 8(d) was passed in 2001, to extend this section to cover the administering oruse of any controlled drug, so that it extends to crack and heroin.

However, in order to strengthen the laws on drug dealing, particularly in crack, Part 1 of the Anti-socialBehaviour Act (2004) creates powers for the police and the courts to close down premises where there has been Class A drug use, production or supply, together with serious nuisance or disorder. In the light ofthese powers, although the amendment (Section 8d) to the current Misuse of Drugs Act has been passed,the Government is delaying its implementation to see if it will be necessary and is due to review thesituation in 2005. Until then, the restrictions under Section 8 remain, as outlined in the bullet points above.

The Medicines Act 1968This covers the manufacture and supply of medicinal products (mainly drugs) of all kinds. It divides drugs into three categories:

• Prescription only – can only be sold or supplied by a pharmacist working from a registered pharmacy.The drug must have been prescribed by a doctor

• Pharmacy medicines – can be sold without a prescription, but only by a pharmacist

• General sales list – can be sold without a prescription by any shop, but certain advertising, labellingand production restrictions apply

The information on these two pages has been adapted from Drugscope and Release. Both organisationscan provide more detailed information and advice. (See ‘Useful Addresses’ for details).

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Further ReadingDual Diagnosis: Substance Misuse and Psychiatric Disorders G. Hussein Rassool Blackwell Science (2002) Available from Amazon Price: £24.99

Advances in Quality Care – Spotlight on health/dual diagnosis “looking after myself”Cassette tapes from Rethink conference: National Schizophrenia Fellowship in Partnership with AlcoholConcern and SCODA: 10 November (1998)

Meeting Complex Needs: The Future of Social Care.Rankin, J and Regan, SAvailable from Turning Point www.turning-point.co.uk

Counselling and Psychotherapy Resources DirectoryPublished annually by British Association for Counselling, 1 Regent Place, Rugby, Warwickshire, CV212PJ. Tel: 01788 550899

Does severe mental illness run in families?Genetic counselling for schizophrenia and allied disordersRethink Fact Sheet 9

Drug Problems: Where to Get Help ISBN 190431905X Drugscope (see ‘Useful Addresses’)Price: £20A comprehensive listing of drug treatment agencies in England. These include the major national andregional organisations, Drug (and Alcohol) Action Teams and drug user organisations. It covers advice and information, harm reduction, counselling, prescribing, rehabilitation and aftercare services, as well as specialist provision for young people

Factsheets are periodically published in Drugscope’s magazine Druglink. For a full listing of resources seeDrugscope’s website

Dual diagnosis – mental illness and drug/alcohol problems - Rethink Fact Sheet 7

Dual diagnosis of severe mental health problems and substance abuse/dependence: a major priority formental health nursing. K Gournay, T. Sandford, S. Johnson, G. Thornicroft (1997) Journal of Psychiatric and Mental Health Nursing

Drug misuse and mental health: learning the lessons on dual diagnosis. A report of the All PartyParliamentary Drugs Misuse Group (2000)

Mental Health and Social Exclusion (2004)ISBN 185112-7178Available free from ODPM Publications Tel 0870 1226 236 or downloadable fromwww.socialexclusionunit.gov.uk/

Integrated treatment for dual disorders: a guide to effective practice.Mueser K.T., Noordsy D.L., Drake R.E., Fox L. London Guilford Press (2003)

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Keys to engagement: review of care for people with severe mental illness who are hard to engage with servicesThe Sainsbury Centre for Mental Health (see ‘Useful Addresses’)

The National Electronic Library for Health is a useful website, with a comprehensive mental health section:www.nelmh.org

New Guide to Medicines and Drugs (2001), British Medical Association ISBN 0-751-327-379Published by Dorling Kindersley Ltd. UK

Perspectives on multiple needs: working with individuals who experience mental health and substancemisuse problemsThe CASA Multiple Needs Service September (1998)

Street drugs: the facts explained, the myths exploded Andrew Tyler (1995) ISBN 0-340-60975-3Hodder & Stoughton

Substance Use: Guidance on good clinical practice for Nurses working within mental health. Coyne, P.Lambert, E. Carroll, J. (2004) London. ANSA/Department of Health (forthcoming)

Substance misuse and mental health co-morbidity (dual diagnosis): standards for mental health services.Abdulrahim D. Health Advisory Service (2001)

Rethink’s publications and factsheets are available from the Rethink National Advice Service. They includeinformation on:

• Schizophrenia• Bipolar Disorder• Anxiety disorders• Schizoaffective disorder• Depression• Personality disorders• Treatments

and many other topics affecting people with mental health problems. The Rethink Diversion Toolkit is alsoa useful resource

Turning Point has published a number of reports exploring issues which are often relevant to people withmultiple needs. These include:

• Getting it right for young people: a vision for young people’s social care (2003)• Waiting for Change: treatment delays and the damage to drinkers (2003)• Routes into treatment: drugs and crime (2004)

These are available free from Turning Point

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Useful Addresses

Addaction67-69 Cowcross StreetLondon EC1M 6PUTel: 020 7251 5860Fax: 020 7251 5890Website: www.addaction.org.ukE-mail: info@addaction.org.uk

Addaction helps individuals and communities to manage the effects of drug and alcohol misuse and hasover fifty projects in England within communities and prisons.

Adfam Waterbridge House32-36 Loman StreetLondon SE1 0EHTel: 020 7928 8898Open 10am - 5pm Monday-Friday, answering machine at all other times.National charity for families of drug users. Offers confidential support and information. Callers can ring asoften as they need and Adfam will call people back if the cost of a call is a problem.Fax: 020 7928 8923Website: www.adfam.org.ukE-mail: admin@adfam.org.uk

Adult Children of AlcoholicsTel: 020 7229 4587

A fellowship of men and women who have been raised in an alcohol environment and who need support.

African Caribbean Mental Health Association (ACMHA) 49 Effra Road Suite 37BrixtonLondon SW2 1BZTel: 020 7737 3603Fax: 020 17924 0126

The African Caribbean Mental Health Association comprises a community mental health centre that provides a wide range of care services to the black community. They also address the problem of racism in the care and treatment of black people.

Al-Anon Family Groups (UK and Eire)61 Great Dover StreetLondon SE1 4YFTel: 020 7403 0888 (Open 24 hours a day, 365 days a year)Website: www.al-anonuk.org.uk

For families and friends of alcoholics. Al-anon Family Groups provide understanding, strength and hope toanyone whose life is, or has been, affected by someone else’s drinking.

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Alcohol Concern Waterbridge House32-36 Loman StreetLondon SE1 0EETel: 020 7928 7377 Fax: 020 7928 4644 E-mail: contact@alcoholconcern.org.uk Website: www.alcoholconcern.org.uk

Alcohol Concern is the national agency on alcohol misuse. They work to reduce the incidence and costs of alcohol-related harm and to increase the range and quality of services available to people with alcohol-related problems. The Mental Health & Alcohol Misuse Project provides fact sheets, a newsletter and webpages to share good practice among clinicians and professionals. For more information contact SladeCarter (scarter@alcoholconcern.org.uk).

Alcoholics AnonymousTel: 020 7352 3001 (Open 10am-10pm 7 days a week, 365 days a year)Website: www.alcoholics-anonymous.org.uk

Alcoholics anonymous is a fellowship of men and women who share their experience, strength and hopewith each other that they may solve their common problem and help others to recover from alcoholism.Out-of-hours answering machine. A.A. will return messages. Will provide a comprehensive list of privateclinics around the country for drug, alcohol and other addictions on request.

Association of Nurses in Substance MisusePO Box 146YelvertonTavistock PL20 7ZJTel: 0807 241 3503Website: www.ansa.uk.netE-mail: ansa@fsmail.net

ANSA welcomes all professionals who work in the area of substance abuse.

British Association for Counselling and PsychotherapyBACP House35-37 Albert StreetRugbyWarwickshire CV21 2SGTel: 0870 443 5252E-mail: bacp@bacp.co.ukWebsite: www.bacp.co.uk

The British Association for Counselling and Psychotherapy provides training and a register of registeredpractioners across the country

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CASA Multiple Needs Service75 Fortess RoadLondon NW5 1AGTel: 020 7428 5954 Fax: 020 7428 5953

CASA was developed to address the gaps in service provision for people who experience mental healthand substance misuse services. It adopts an holistic approach to these problems, working with the wholeperson and their presenting difficulties. The Multiple needs Service (MNS) has worked with clients inIslington and Camden since late 1995. It also offers specialist training nationally.

Carers UK20-25 Glasshouse YardLondon EC1A 4JSTel: 020 7490 8818Carersline: 0345 573 369Fax: 020 7490 8824

Carers UK is the national voice of carers. They provide advice for carers across the UK.

Chinese Mental Health AssociationOxford HouseDerbyshire StreetLondon E2 6HBTel: 020 7613 11008 (9am-5.30pm Monday-Friday)Fax: 020 7729 0435

The Chinese Mental Health Association is a voluntary organisation and registered charity set up to helpChinese people who are sufferers of mental illness. The association aims to promote mental healtheducation in the Chinese community and to raise awareness amongst the mainstream healthcare providersregarding Chinese mental health issues.

Cocaine AnonymousTel: 020 7284 1123 (Open 24 hours a day, 365 days a year)Website: www.cauk.org.ukCocaine Anonymous is a fellowship of men and women who use the 12 step, self-help programme to stopusing cocaine and all other mind-altering substances. There are meetings all over the country.

Council for Involuntary Tranquilliser Addiction (CITA)Cavendish HouseRooms 15 & 17Brighton RoadWaterlooLiverpool L22 5NGHelpline: 0151 949 0102 (10am-1pm Monday-Friday)Fax: 0151 284 8324

CITA helps patients and families to cope with addiction to benzodiazepines and other prescribed drugsespecially anti-depressants, and with withdrawal. In addition to the helpline, CITA has a list of self helpgroups across the country.

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DrinklineFreephone: 0500 801 802Tel: 020 7332 0202 (Open 11am-11pm Monday-Friday, dial and listen service 24 hours a day)

Drinkline is the National Alcohol Helpline. They provide information and self-help materials, help to callersworried about their own drinking, support to the family and friends of people who are drinking and adviceon where to get help.

Drug and Alcohol Women’s Network31 Great Sutton StreetLondon EC1V ODXTel: 020 7253 6221 Monday/Tuesday/Thursday 9.30am-5.30pm

Set up to help and support women working in the field of drugs and alcohol. The Greater LondonAssociation of Alcohol Services is also at the same address. This aims to create and support a network ofalcohol services in London.

DrugScope32 - 36 Loman Street London SE1 0EE Tel: 020 7928 1211 Fax: 020 7928 1771Website: www.drugscope.org.ukE-mail: info@drugscope.org.uk

DrugScope provides information and publications on a wide range of drug related topics. The informationservice is open from 10am-4pm Monday-Friday on 08707 743 682.

FRANK (formerly the National Drugs Helpline)Freephone: 0800 77 66 00 Confidential, daily 24 hour service:Website: www.talktofrank.com

Campaign from the Department of Health and the Home Office, supported by the DfES. Information andadvice on drugs to anyone concerned about drugs and solvent/volatile substance misuse, including drugmisusers, their families, friends and carers. Information and advice is available in several languages.

Health Information ServiceFreephone: 0800 66 55 44

An information-only service, run by the NHS. 10am-5pm Monday-Friday, answering machine outside thesehours. The service operates on a local basis. Calls are automatically routed to your nearest local office. Ageneral health information service, but it provides details of addiction units and self-help groups aroundthe country.

Hearing Voices Network91 Oldham StreetManchester M4 1LWTel: 0161 834 5768Fax: 0161 228 3896Website: www.hearing-voices.org

The Hearing Voices Network offers information, support and understanding to people who hear voices andthose that support them.

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JAMIJewish Association for the Mentally Ill16a North End RoadGolders GreenLondon NW11 7PHTel: 020 8458 2223Fax: 020 8458 1117Website: www.mentalhealth-jami.org.uk/

JAMI provides essential daycare, social work, counselling advice, information, and social activities forpeople suffering from severe mental health problems, their families and carers.

Kaleidoscope Project40-46 Cromwell RoadKingston upon ThamesSurrey KT2 6RETel: 020 8549 2681

In addition to a methadone maintenance and reduction service, needle exchange, day programme andrecreation, counselling, crèche and detoxification unit, the Kaleidoscope Project runs professional trainingcourses in drug awareness and education.

Manic Depression Fellowship (MDF)Castle Works21 St. George’s RoadLondon SE1 6ESTel: 020 7793 2600Fax: 020 7793 2639E-mail: mdf@mdf.org.uk Website: www.mdf.org.uk

The Manic Depression Fellowship works to enable people affected by manic depression to take control oftheir lives. It does this through supporting and developing self help opportunities for people affected bymanic depression, providing an information service, influencing the improvement of treatments and servicesto promote recovery and tackling discrimination. It has a number of self help groups across the UK.

MIND (National Association for Mental Health)Granta House,15-19 BroadwayStratfordLondon E15 4BQTel: 020 8519 2122Help Line: Mind info-line: 020 8522 1728 / 0845 766 0163E-mail: contact@mind.org.ukFax: 020 8522 1725

Mind is a leading mental health charity in England and Wales, working for a better life for everyone withexperience of mental distress. As well as printed information, Mind has a very comprehensive websiteoffering advice, information and background briefings on a wide range of mental health issues and mentalhealth problems (add including dual diagnosis).

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Mental Health Foundation7th Floor, 83 Victoria StreetLondon SWIH 0HWTel: 020 7802 0300Fax: 020 7802 0301Website: www.mentalhealth.org.ukE-mail: mhf@mhf.org.uk

The Mental Health Foundation is a leading UK charity providing research and community projects toimprove support for people with mental health problems and people with learning disabilities. It providesinformation on specific mental health problems, where to get help, treatment and rights.

Narcotics AnonymousTel: 020 7730 0009 (10am-10pm 365 days a years. Out of hours answering machine, calls will be returned)Website: www.ukna.org

NA is a fellowship of men and women for whom drugs had become a major problem. Using the 12 stepself-help model recovering addicts meet regularly to help each other stay clean. The have meetings all overthe country.

National Asian DrinklineTel: 0990 133480 (Counselling 1pm-8pm Monday-Friday, dial and listen service 24 hours a day, 365 days a year)

National Association of Children of AlcoholicsPO Box 64FishpondsBristol BS16 2UHFreephone: 0800 358 3456 (Open 9am-5pm Monday-Friday. Out of hours answering machine. Calls will be returned)Fax: 0117 924 8005

The National Association for Children of Alcoholics offers advice, information and support to children ofalcoholics. They also work with professionals who deal with children of alcoholics.

National Institute for Mental Health in England (NIMHE)Blenheim HouseWest OneDuncombe StreetLeeds LS1 4PLTel: 0113 254 3811Website: www.nimhe.org.ukE-mail: Ask@nimhe.org.uk

NIMHE aims to improve the quality of life for people of all ages who experience mental distress. They helpall those involved in mental health to implement positive change, provide a gateway to learning anddevelopment, offer new opportunities to share experiences and one place to find information. ThroughNIMHE’s local development centres and national programmes of work (eg on dual diagnosis, personalitydisorder and women) they support staff to put policy into practice and to resolve local challenges indeveloping mental health.

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Overcount Drug Information Agency20 Brewery StreetDumfries Scotland DG1 2RPTel: 01387 770 404 (8am-9pm, answering machine at other times. All calls will be returned)

A unique agency offering information on over the counter drugs. Run by David Grieve, this is a free,independent and confidential service for anybody who fears that they may be addicted, or for friends andfamily wishing to know more about over the counter drugs.

Release388 Old Street London EC1V 9LTHelpline: 020 7729 9904Administration: 020 7729 5255Legal and Drugs Helpline: 020 7729 9904 (10am-5.30pm, Monday-Friday)Website: www.release.org.ukE-mail: ask@release.org.uk

Release is a national organisation committed to informing and advising the public about drugs, the law andhuman rights.

Rethink severe mental illness30 Tabernacle StreetLondon EC2A 4DDTel: 0845 456 0455Fax: 020 7330 9102E-mail: info@rethink.orgWebsite: www.rethink.orgCarers’ website: www.rethinkcarers.org

Rethink has more than 30 years experience of helping people affected by severe mental illness and theirfamilies recover a meaningful life. As well as running over 400 mental health services, they have a networkof more than 120 support groups across the country.

Rethink National Advice Service28 Castle StreetKingston upon ThamesSurrey KT1 1SSTel: 020 8974 6814 (Mon, Wed, Fri 10am-3pm; Tues and Thurs 10am-1pm)E-mail: advice@rethink.org

The Rethink National Advice Service provides information and advice on all aspects of mental illness andissues affecting people with mental illness to people with mental illness, their carers, friends and family andprofessionals.

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Revolving DoorsUnit 29, The Turnmill63 Clerkenwell RoadLondon ECIM 5NPTel: 020 7253 4038Fax: 020 7553 6079Website: www.revolving-doors.co.uk

Revolving Doors Agency is the UK's leading charity concerned with mental health and the criminal justicesystem. It runs practical schemes in police stations, prisons and courts to support people who have “fallenthrough the net” of mainstream services. It uses this experience to provide project development support toother agencies and to conduct research and policy work at local and national level.

Sainsbury Centre for Mental Health134-138 Borough High StreetLondon SWI 1LBTel: 020 7403 8790Fax: 020 7403 9482Website: www.scmh.org.uk

The Sainsbury Centre for Mental Health is a charity that works to improve the quality of life for people withsevere mental health problems. It carries out research, development and training work to influence policyand practice in health and social care.

SANEIst Floor, Cityside House40 Adler StreetLondon E1 1EETel: 020 7375 1002Fax: 020 7375 2162SANELINE: 0845 767 8000SANE is one of the UK’s leading charities concerned with improving the lives of everyone affected bymental illness.

Survivors Speak Out34 Osnaburgh StreetLondon NW1 3NDTel: 020 7916 6991

Survivors Speak Out is a nationwide organisation for people who are defined psychiatric system survivors.This is a campaigning organisation trying to bring change through survivor contact and empowerment, byputting people in touch with each other.

Tasha(Tranquillisers, Anxiety, Stress, Help Association) Tel: 020 8560 6601 (6pm-12am only, 365 days a year)Website: www.tasha-foundation.org.uk

The TASHA foundation provide confidential information, support, training and counselling to individualsaffected by mental health difficulties and problematic benzodiazepine usage.

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Turning PointNew Loom House 101 Back Church LaneLondon E1 1LUTel: 020 7702 2300Website: www.turning-point.co.ukE-mail: info@turning-point.co.uk

Turning Point is the UK's leading social care charity providing services for people with complex needs acrossa range of health and disability issues primarily substance misuse, mental health and learning disability. Ithas residential and community-based services in 200 locations in England and Wales. Turning Point providesservices for people with concurrent mental health and substance misuse problems.

UK Council for PsychotherapyUnited Kingdom Council for Psychotherapy 167-169 Great Portland Street London W1W 5PF Tel: 020 7436 3002 Fax: 020 7436 3013 Website: www.psychotherapy.org.ukE-mail: ukcp@psychotherapy.org.uk

The UKCP promotes psychotherapy for the public benefit, research and education in psychotherapy itsdissemination as well as protection of the public through high standards of training and practice inpsychotherapy. They publish the National Register of Psychotherapists annually and only psychotherapistswho meet the training requirements and abide by its ethical guidelines are included.

Young Minds (Children’s Mental Health Charity)2nd Floor, 102/8 Clerkenwell RdLondon EC1M 5SATel: 020 7336 8445Helpline: (Parents’ information service) 0800 018 2138Fax: 020 7336 8446Website: www.youngminds.org.ukE-mail: enquiries@youngminds.org.uk

Young Minds is the national charity committed to improving the mental health of all children and young people.

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Access to services 2, 24-25, 28, 33, 36-38, 44, 47-50, 52, 55, 58, 60, 66, 81, 83Alcohol 1-3, 5, 7, 9, 11-13, 17,19, 20, 24, 26, 34-37, 40, 43, 52, 54, 62-66, 69, 70, 75-77,

81-83, 86, 88, 89, 91, 93Alkyl nitrites 80Amphetamines 31, 73, 78, 84Anabolic steroids 74, 84Anti-depressants 39, 90Antipsychotics 34, 39Anxiety disorders 15, 16, 39, 87Anxiolytics 39, 40Art therapy 40, 42Assessment 3, 6, 23-27, 29-30, 32, 36, 38, 40, 44, 47, 55, 59, 62, 63, 65, 70, 81, 83

Risk assessment 26-27, 29, 32, 62-63, 65Bipolar disorder 3, 18, 40-41, 87Caldicott Report 28Cannabis 3, 12-13, 43, 50, 77, 84-85Care co-ordination 6, 30, 63, 82Care planning 32Care Programme Approach (CPA) 6, 23, 30, 62, 81Cocaine 3, 9-10, 12, 19, 43, 73-75, 84, 90Cognitive Behavioural Therapy 20, 48Complementary Therapies 3, 23, 34, 43, 66Counselling 3, 34-35, 36, 38, 40, 42, 46, 52, 86, 89, 92-93, 95Crack cocaine 12, 74-75Cycle of change 43, 45Delusions 17-18, 73-74, 78Depressants 39, 76, 90Dialectical Behavioural Therapy 40Diversity 50, 52

Black minority ethnic communities 23, 50-52Lesbian, gay, bisexual, transgender 23, 50, 54, 72, 80Women 23, 50, 52-53, 81, 77, 79, 88-91, 93

Drama therapy 40, 42Dual Diagnosis Good Practice Guide 5, 60, 63, 69, 82Ecstasy 10, 12, 77-78, 84Engagement 20, 21, 25-26, 32, 43-45, 54, 58, 63, 66, 72, 81, 87GHB 77Good Practice Recommendations: 32, 51, 53, 55, 61

Assessment 3, 6, 23-27, 29-30, 32, 36 38, 40, 44, 47, 55, 59, 62, 63, 65, 70, 81, 83Meeting diverse needs 23-24, 50Service delivery 24, 57, 60, 81Working with mental illness 3, 5, 15, 21, 30-31, 33, 39, 40, 41, 48, 58, 60, 72, 78, 81-83, 86-87, 90, 94-95

Hallucinations 17, 74-78Hallucinogens 78Harm Reduction 7, 33, 35, 69, 83, 86Heroin 11-12, 34, 37, 75, 79, 80, 84-85Khat 52, 75LSD 11, 78-79, 84Mania 3, 19, 39, 73-74Medicines Act 1968 (The) 85

Index

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Mental Health Act 1983 (The) 6, 38, 83Mental Health National Service Framework (NSFMH) 6, 81Methadone 33-34, 37, 79-80, 84, 92Misuse of Drugs Act 1971 (The) 84Models of Care 6-7, 30-32, 36, 82-83Mood stabilisers 39-40Motivational Interviewing 35, 43, 46, 63, 70Mushrooms 78-79, 84Opiates/opioids 43, 79Person-centred planning 32Personality disorder 2, 19-21, 39-41, 60, 69, 87, 93Psychotherapy 20, 40-42, 86, 89, 96Relapse prevention 3, 43, 48, 63, 70Schizophrenia 17, 19, 31, 39, 42, 50, 71, 78, 86, 87Schizoaffective disorder 19, 39, 87Sedative-Hypnotics 76Social care issues 58Solvents 12, 80Stimulants 3, 10, 73Substance Use 3, 9, 11-12, 24-25, 52, 65, 69, 87

Factors affecting use 11Patterns of use 9Types of use 12

Training 5, 25, 29, 48, 52-53, 55, 57, 59, 61-67, 81-82, 89-90, 92, 95-96Tranquillisers 12, 76, 84, 95Treatment 2, 5-6, 9, 13, 15, 20-21, 23-27, 32-40, 42-45, 47, 49-52, 55, 58-60, 62, 69-70, 72,

082-83, 86-88, 92-93Active treatment 43, 47, 70Criminal Justice interventions 35, 37Involving service users, families and carers 49Mental Health services 1-2, 5, 15, 19, 23-24, 30-31, 35, 39, 48, 59-60, 65, 81-82, 87, 94Substance Misuse services 6, 9, 12, 23, 29, 33, 44, 58-59, 64-66, 70, 90

Updated Drug Strategy 7, 12, 37, 83Volatile substances 80

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Turning PointNew Loom House 101 Back Church LaneLondon E1 1LUTel: 020 7702 2300Website: www.turning-point.co.ukE-mail: info@turning-point.co.uk

Registered Charity Number: 234887Registered Social Landlord and Company Limited by Guarantee in England and Wales (no.793558).

Turning Point is the UK's leading social care charity providing services for people with complex needs acrossa range of health and disability issues primarily substance misuse, mental health and learning disability. Ithas residential and community-based services in 200 locations in England and Wales. Turning Point providesservices for people with concurrent mental health and substance misuse problems.

Rethink severe mental illness30 Tabernacle StreetLondon EC2A 4DDTel: 0845 456 0455Fax: 020 7330 9102Website: www.rethink.org E-mail: info@rethink.org

Registered Charity Number: 271028Company Registered in England Number: 1227970

Rethink has more than 30 years experiwence of helping people affected by severe mental illness and theirfamilies recover a meaningful life. As well as running over 400 mental health services, we have a networkof more than 120 support groups across the country.

Copyright 2004 © Rethink and Turning Point.All rights reserved. No part of this booklet may be reproduced or transmitted in any form or by any means,electronic or mechanical, including photocopying, recording or by any information storage and retrievalsystem without the permission, in writing, of Rethink and Turning Point.